Contraception, Sterilization & Infertility - Women's Health 2025 PDF

CONTRACEPTION, STERILIZATION, & INFERTILITY Women’s Health 2025 Dr S Ryan 1 TOPICS Contraception ­ Hormonal Contraceptives ­ Barrier Contraceptives ­ Intrauterine Devices ­ Natural Family Planning Emergency Contraception Sterilization Infertility...

CONTRACEPTION, STERILIZATION, & INFERTILITY Women’s Health 2025 Dr S Ryan 1 TOPICS Contraception ­ Hormonal Contraceptives ­ Barrier Contraceptives ­ Intrauterine Devices ­ Natural Family Planning Emergency Contraception Sterilization Infertility 2 OBJECTIVES Compare and contrast the various forms of birth control Know the indications and contraindications when prescribing the various methods of contraception Discuss the options available for both men and women regarding sterilization Identify the approaches available for infertility including the evaluation of the male and female Formulate a plan of care for those dealing with infertility, including other members of the health care team 3 4  45% of all pregnancies in the US are unintended UNINTENDED Most occurred in women who PREGNANCIES did not use contraception or used it incorrectly MC reason – they did not think they could get pregnant 5 HORMONAL CONTRACEPTION COMBINATION PILLS PROGESTIN-ONLY PILL RINGS & PATCHES DMPA IMPLANTABLE RODS 6  Choice of method involves many factors Life-style Career choices Who is responsible CONTRACEPTION Pts need to understand that contraceptive methods do NOT provide protection from STIs ALWAYS consider overall risk to benefit on an individual basis 7 CONTRACEPTION Pill, OCPs, OCs, or BC pills ­ The most effective reversible pregnancy prevention available Injectable preparations ­ Implantable hormonal rod §Hormone containing IU systems §Patches & rings Reminder: discuss high-risk behaviors, safe sex, & the need for condoms for additional protection 8 CONTRACEPTIVE COMPONENTS Progestin Compounds Estrogen Compounds Norgesterel Ethinyl estradiol Ethynodiol diacetate Estradiol valerate Norethynodrel Norethindrone Desogestrel* Norgestimate* Drisporenone* 9  Most contain combinations of estrogen & progesterone They prevent ovulation COMBINATION PILLS If ovulation occurs: Progesterone - thickens cervical mucus, inhibits sperm migration, creating difficulty implanting Estrogen - increases efficacy of progesterone & stabilizes the endometrium Cycles are regulated, less breakthrough bleeding 10  Classic regimen – 21 days of active hormone & 7 days of placebo Continuous regimens produce shorter or less frequent menstrual periods One period every 3 or 12 months * COMBINATION PILLS Combined pills are contraindicated in: Women > 35 yrs of age who smoke** H/O thromboembolism H/O CAD, CHF, CVA H/O migraine with or w/o aura 11 COMBINATION PILLS DISCONTINUE these with: ­Increases in BP ­Esp pts with H/O HTN ­Worsening migraines 12 COMBINATION PILLS Shorter, less painful, predictable periods Lower incidence of: Benefits: Endometrial & ovarian cancer Benign breast & ovarian disease Pelvic infection Ectopic pregnancies Breakthrough bleeding occurs in 10-30% of women Usually resolves spontaneously on low dose OCs 13  AKA: “mini pill” ­Make cervical mucus thick & relatively impermeable ­Especially good for: ­ Lactating women PROGESTIN- ­ Women > age 40 yrs ONLY PILLS ­ Where estrogen containing formulas are contraindicated ­Pt ed: Take at approx the same time EVERY DAY, starting on 1st day of menses ­ *If > 3hrs late, another form of contraception must be used for the next 48 hrs 14 D/C OCP, start Immediate Evaluation nonhormonal methods Loss of vision, diplopia Possible retinal artery thrombosis Unilateral numbness, weakness Possible stroke HORMONAL Severe chest/ neck pain Possible MI CONTRACEPTIVES: Slurring of speech Possible stroke SIDE EFFECTS Severe leg pain, tenderness Possible thrombophlebitis Hemoptysis, acute SOB Possible pulmonary embolism Hepatic mass, tenderness Possible hepatic neoplasm, adenoma 15 Continue OCP Immediate Evaluation Amenorrhea Possible pregnancy Breast mass Possible breast cancer RUQ pain Possible cholecystitis, HORMONAL cholelithiasis CONTRACEPTIVES: Severe headache Possible stroke, migraine SIDE EFFECTS headache Galactorrhea Possible pituitary adenoma 16 NEW, POTENTIALLY SAFER BIRTH CONTROL PILL Nextstellis - combines a novel estrogen, estetrol, with the progestin drospirenone. ­ Approved by the US Food and Drug Administration on April 16, 2021. “Almost all currently prescribed OCs are formulated with ethinyl estradiol, a synthetic and highly potent estrogen. In contrast to ethinyl estradiol, estetrol is naturally occurring, and… is produced from a plant source. An earlier clinical trial found that an OC formulated with estetrol and drospirenone had substantially less impact on coagulation markers than an ethinyl estradiol- drospirenone or an ethinyl estradiol-levonorgestrel OC.” 17  NEW OCP APPROVED BY FDA Available early 2024 Nonprescription OCP 18  Transdermal patch - a combination patch that lasts for 1 wk Start during the first 5 days of menses; replace weekly x 3 wks ­ 4th wk is patch free – allows for withdrawal bleeding Place on clean, dry skin ­ Buttocks, upper outer arm, or lower abd CONTRACEPTION PATCHES *Has decreased efficacy is those > 198 lbs* 19 CONTRACEPTION – RINGS Same amount of hormones are released daily Used once a month ­Placed in vagina at start of menses & left in place x 3 wks ­ Withdrawal bleeding occurs with removal of ring 20 BARRIER CONTRACEPTIVES CONDOMS DIAPHRAGM 21  Have higher failure rates Dependent upon proper use before or at the time of intercourse Damage can occur to the barrier itself CONTRACEPTIVES Benefits: - BARRIERS Cheaper, widely available Provide some protection against transmission of STIs Gonorrhea; herpes; chlamydia; HIV; HPV infection 22 CONTRACEPTIVES - CONDOMS 2 types: ­ Sheaths worn over the penis ­ Sheaths worn inside the vagina (female condom) ­ Must be left in place 6-8 hrs after intercourse Only latex condoms protect against HIV Advise pts to seek medical care with 120 hrs if the condom slips/breaks so emergency contraceptive can begin 23 CONTRACEPTIVES – DIAPHRAGMS* Dome shaped latex device; fits over the anterior vaginal wall & cervix Used with contraceptive jelly/cream Inserted 6 hrs prior to intercourse ­ Left in place for 6-8 hrs after, but not > 24 hrs Avoid using talcum powder on the diaphragm Requires fitting from a healthcare practitioner ­ Re-fit with weight change, vaginal birth or pelvic surgery SE: higher rate of UTIs 24  CONTRACEPTIVES – CERVICAL CAPS Cover the cervix only ­Easier to displace, harder to fit ­Must remain in place 6 hrs post intercourse – not > 48 hrs Higher incidence of: ­ Toxic Shock Syndrome (TSS) ­ Cervicitis 25 CERVICAL CAP VS DIAPHRAGM 26 CONTRACEPTIVES – SPONGES* Small, pillow shaped sponge that fits over the cervix ­ Contains spermicide Can remain in place for 24 hrs More effective in nullip women Increased risk of TSS if left in place > 30 hrs 27 LONG ACTING REVERSIBLE CONTRACEPTIVES INTRAUTERINE DEVICES IMPLANTS 28  Includes: Intrauterine devices (IUDs) Hormone-eluting subdermal implants Good options for: LONG ACTING Those with contraindications to REVERSIBLE estrogen containing compounds Those who desire a rapid return to CONTRACEPTION fertility Have higher up-front costs* 99% effective form of birth control 29  Adolescents are ideal candidates* Contraindications: Congenital or acquired distortions of uterus Bicornuate or septate uterus, fibroids, cervical stenosis IUDs Current AUB Active pelvic infection Pregnancy Risks associated: Increased incidence of PID** Spontaneous expulsion Uterine perforation Can become embedded in uterine wall (10-16%) Higher risk of ectopic pregnancy 30  Types available in US: ­Hormonal – release levonorgesterol ­ Thickens cervical mucus ­ Place within first 7 days of LMP or during menses ­ SE: irregular bleeding/ spotting* ­ Amenorrhea ­ Increased risk of ovarian cysts IUDs ­ Copper IUD – ParaGard ­ Can be used while breastfeeding ­ May inhibit implantation ­ Creates an inflammatory response that is toxic to sperm and ova, preventing pregnancy ALL must be checked for placement in 4 wks 31  Depot medroxyprogesterone (DepoProvera) - injectable progestin ­ IM/sc every 3 mos within first 5 days of menses ­ Lasts for at least 14 wks (“safety margin”) ­ FDA warning: concern over bone mineral IM INJECTION density (BMD) has resulted in a warning to limit use to 2 yrs ­ ACOG does not recommend limiting use of DMPA to 2 yrs as the effects of DMPA on BMD are intermediate and reversible ­ Always consider overall risk to benefit on an individual basis 32  Etonogestrel (Nexaplanon, Implanon) ­ Implanted inner side of upper arm ­ Must be trained in insertion & removal ­ Place within first 5 days of LMP ­ Approved for up to 3 yrs (99%) IMPLANTS ­ Also good for: ­ Dysmenorrhea from endometriosis ­ Those who cannot use IUDs ­ SE - similar to those with IUDs ­ Contraindicated in those with hormone responsive conditions (breast Ca, etc) 33 IMPLANTS Advantages Disadvantages Good for pts with: Irregular bleeding/amenorrhea* ­ HTN ­ Smokers > 35 yrs Small amount of weight gain ­ Seizure disorders Contraindicated with: ­ Unevaluated vaginal bleeding ­ Sickle cell anemia ­ Breast malignancy ­ Those who can’t take estrogen ­ H/O thromboembolism or containing preps cerebrovascular disease ­ Liver dysfunction/disease 34 NATURAL FAMILY PLANNING 35  Avoiding pregnancy by either avoiding intercourse around the time of ovulation OR using barrier methods & spermicides during the time of ovulation FERTILITY Examples: AWARENESS ­ Calendar method ­ Calculates fertile period ­ Basal body temperature (BBT) method ­ Basal body temp increases by 0.5°F – 1°F with ovulation ­ Cervical mucus method 36 EMERGENCY CONTRACEPTION PLAN B NEXT CHOICE 37 EMERGENCY CONTRACEPTION (ECP) – “MORNING AFTER PILLS” Used with unprotected sexual intercourse within 72 hrs* & if there are no medical contraindications Inhibit ovulation ­ Work by preventing ovulation or fertilization ­ Do not affect implantation so they are ineffective for use as a form of abortion 38  Plan B One Step & Next Choice One Dose – MC preps ­ OTC medications ­ MC side effect – nausea/vomiting x 1-2 days EMERGENCY Progestin only regimens ­ Ex: Levonelle CONTRACEPTION ­ Can be taken up to 72 hrs after unprotected intercourse Copper IUD (ParaGard) – most effective method (99.9%) if inserted within 5 days of unprotected sex 39  EMERGENCY CONTRACEPTION ellaOne – ulipristal acetate §“morning after” pill ­ Effective up to 5 days after unprotected intercourse ­ Requires a prescription All methods prevent ovulation & fertilization ­ They do NOT prevent implantation NOR will they terminate an existing pregnancy 40 PATIENT CONSIDERATIONS § Plan B may work less effectively at standard doses in people with a body weight of over 165 lbs §Plan B does not have weight restriction, so patients above this body weight can still take it §ellaOne may work better for pts weighing over 165 lbs §For pts >195 lbs or more, ellaOne is also less effective §Copper IUDs have no weight limit 41 STERILIZATION MALE FEMALE 42 STERILIZATION MC used method of controlling fertility in the US Should be considered permanent Reversal outcomes have poor rates of success and are expensive Techniques: Male – vasectomy – prevents sperm passing into the ejaculate Female – permanently occludes the fallopian tube 43  Vasectomy – occludes the vas deferens Very effective. Complete azoospermia is not obtained until 10 wks post procedure STERILIZATION - MALE Complications (5-10%) Bleeding Hematoma Acute & chronic pain Local skin infection Depression & change in body image 44 STERILIZATION - MALE 45  Can be done as out-pt procedure under local, regional or general anesthesia Electrocautery Hulka clip – most reversible method STERILIZATION - Falope ring FEMALE Filshie clip Minilaparotomy is MC surgical approach used Allows for occlusion of fallopian tubes by clips, rings or cautery 46 STERILIZATION - FEMALE 47  Hysteroscopy – access to fallopian tubes via the cervix Essure system Stainless steel & nickel titanium coil is inserted into STERILIZATION - each fallopian tube FEMALE Complications: Infection Bleeding Ectopic pregnancy 48  Pre-sterilization counseling should include: ­ Permanent nature of the procedure ­ Alternative methods available ­ Reason for choosing sterilization STERILIZATION ­ Screening for risk indicators of regret ­ Details of procedure ­ Including risks & benefits ­ Possibility of failure (ectopic pregnancy) ­ Need to use condoms for protection against STDs 49 INFERTILITY 50 INFERTILITY Inability of a couple to conceive after 12 mos of frequent, unprotected intercourse ­ Women > 35 yrs are determined to be infertile after 6 mos of frequent, unprotected sex & should be evaluated earlier 1 in 6 couples will face fertility issues 51  Conception requires: ­Ovulation of a competent oocyte ­Production of competent sperm ­Patent reproductive tract & INFERTILITY fertilization ­Creation of a viable embryo ­Transport of the embryo into the uterus ­Successful implantation into the endometrium 52  INFERTILITY 3 main components: ­ Female factors (65%) ­ Ovulatory dysfunction – MCC (ex: PCOS) ­ Fallopian tube obstruction, pelvic adhesions, etc ­ Endometriosis – include this in the work up ­ Male factors (20%) ­ Varicocele; oligozoospermia; azoospermia; sperm motility or morphology issues ­ Unexplained/other conditions (15%) Dx of infertility can be devastating to a couple – counseling is an essential component of Rx for both partners 53 INFERTILITY - EVALUATION Female Male H&P H&P ­ Menstrual Hx (regular cycles suggests ovulatory cycles) Semen analysis ­ Ovulation predictor tests, basal ­ Repeat prn body temp F/U with urologist or Uterus evaluation reproductive endocrinologist ­ U/S; hysteroscopy; specializing in male infertility hysterosalpingography; laparoscopy 54  INFERTILITY – ASSISTED REPRODUCTIVE TECHNOLOGY (ART) 2 types: ­Artificial insemination ­AKA: (IUI) intrauterine insemination ­IVF – in vitro fertilization ­MC method used 55 INFERTILITY – IUI Includes conservative measures, to more aggressive ovarian stimulation to intrauterine insemination Ovarian stimulation – for women with anovulation or oligo-ovulation Clomiphene citrate – MC used med Controlled ovarian hyperstimulation Exogenous gonadotropins stimulate follicular development (subcutaneous injections) Intrauterine insemination Washed semen is introduced via catheter into the uterus 56 57 INFERTILITY – IVF > 99% of all ART procedures Involves: ­ Ovarian stimulation to produce multiple follicles ­ Retrieval of oocytes from ovaries ­ Oocyte fertilization in vitro in the lab ­ Embryo incubation in the lab ­ Transfer of embryos into the woman’s uterus thru the cervix 58 59  Couples counseling should include: ­Risk of multiple gestations ­Ethical issues surrounding multifetal pregnancy reduction INFERTILITY ­Emotional stress associated with undergoing ART ­Adoption ­Cost 60 REFERENCES A New, Potentially Safer Birth Control Pill Andrew M. Kaunitz, MD ­ https://www.medscape.com/viewarticle/949975?src=WNL_clfoc _210517_MSCPEDIT_TEMP2&uac=289529HZ&impID=3367709 &faf=1 61 QUESTIONS? 62