Fertility regulation

World without contraception:

- Termination of pregnancy
- Individual/family: physical, mental wellbeing
- Social problems: financial, schooling, housing
- Population crisis

Ideal contraception:
- 100% effective
- No side effects
- No effect on next conception
- Simple, cheap, easy to distribute
- Reversible with simple reversion

- Independent of medical profession
- Acceptable: every culture, religion, politics
- Minimal motivation, independent of intercourse

Effectiveness: how to assess (index, failure types)
- Pearl index: fail rates/100 woman years (of exposure)
- Type:
o User failure: user dependent
o Method failure: user independent

Contraception: (female) natural methods, advantages + disadvantages
- Calendar/rhythm method (safety period):
o Mechanism: Sperm survives 3-7 days; ovum survives 1 day
o Hence avoid coitus in fertile period: 1
st
fertile day -> last fertile day (shortest cycle minus 20; longest
cycle minus 10)
- Advantages:
o Inexpensive
o No side effects
o No medical intervention
o No religious objection
- Disadvantages:
o Difficult for irregular cycles
o Tedious, inconvenient + depend on user motivation
o Need long period of avoiding sex (abstinence)
o High failure rate (24 per hundred women years)

- Lactational amenorrhea
o Definition: temporary postnatal infertility
o Mechanism: amenorrheic + fully breastfeeding (within 6 months after delivery)

Contraception: (female) fertility awareness (not natural), when to avoid sex
- Basal body temperature method: 1
st
day of menstruation -> until 3 days after temperature rise
(body temp rises after ovulation)
- Cervical mucus: when mucus becomes sticky + moist -> until 4 days after cessation
(cervical mucus becomes egg white, i.e. clear, slippery, thin, stretchy)
- Sympto-thermal method: combine both methods above
- Ovulation predictor kit: measures urinary LH level

Contraception: (male) natural method, disadvantages
- Method: coitus interruptus = withdraw penis before ejaculation pulling out
- Disadvantages
o Strong motivation needed
o Difficult to control timing of ejaculation
o Sperm present in pre-ejaculate before penis withdrawal
o High failure rate

Barrier methods: definition, examples, indications
Definition: physical/chemical barrier preventing sperms contacting eggs

Examples:
- Male condom
- Female condom (femidom)
- Femidom
- Other female barriers: diaphragm, sponge, cervical cap
- Spermicide
- Hormonal contraceptive: combined (COC), progesterone only (POP)
- Injectables
- Newer hormonal contraceptives: contraceptive patch, Evra, patch, Nuvaring, vaginal ring
- Implants
- Intra-uterine contraceptive device (IUCD)

Indications:
- Consistent, correct use
- Back up: emergency contraception

Barrier methods: advantages, disadvantages
Advantages:
- Immediate contraception
- No systemic side effects
- Easily accessible

Disadvantages:
- Discomfort
- Reduced sensation (sexual pleasure)
- -> Rely on motivation + compliance of couple

Male condom: indications, advantages
Indications:
- Single use
- Wear before sexual contact
- Check for break/slip
- Withdrawal: hold condom ring, withdraw before penis flaccid
- General: spermicidal condom has no evidence of additional protection -> not recommended

Advantages
- reduce STD/HIV transmission

Female condom: indications, advantage, disadvantages
Indications:
- Under womens control
- Wear before sexual contact

Advantages:
- Allow continual intimacy (at resolution phase of sex)

Disadvantages:
- Awkward
- More expensive

Spermicides: mechanism, example, forms
Definition: inactivate + kill sperm
Example: no-no-sex-no-9 -> nonoxynol-9
Forms:
- Cream, jelly, foam
- Foaming tablets, suppositories
- Vaginal sponge, vaginal film

Spermicides: disadvantages
- Less effective
- STD/HIV transmission (esp. high risk individuals)
- Increase genital lesions

Hormonal contraceptives: types, mechanism; admin routes
Types
1. Combined (estrogen + progestogen)
- Mechanism: inhibit ovulation (major) + thicken cervical mucus

2. Progestogen-only (continuous dose)
- Mechanism: thicken cervical mucus (major) +/- inhibit ovulation

Routes
- Oral pills, patch
- Injectables
- Vaginal rings, progesterone-IUCD, implants

COC (combined oral contraceptive pill): dosage, formulation
Dosage:
- Daily for 21 days + interval for 7 days

Ingredients
- Estrogen = ethinyl-oestradiol (20-35 ug)
- Progestogen = levonorgesterel (2
nd
gen); gestodene, desogestrel (3
rd
gen); drospirenone (4
th
gen)
Note:
- 2
nd
gen = Lenovo (pro) gestrogen -> levonogestrel
- 3
rd
gen = GD/DG -> gestodene, desogestrel
- 4
th
gen = drops none -> drosperinone

COC: advantages
- Highly effective
- Controlled by women
- Reversible
- No increase risk of abortion/fetal anomalies (if exposed in early pregnancy)
- Non-contraceptive benefits
o Regulate menstrual cycle
o Decrease menstrual flow -> dysmenorrhea -> PMS (pre-)
o Decrease CA: endometrium, ovarian (40%)
o Decrease cyst: fx ovarian cyst, benign breast disease
o Decrease PID

- Reversible (1-3 months after stopping)
- Can continue until 50 y.o. (if no contraindications)

COC: disadvantages
Side effects (minor)
- General: nausea, vomiting, dizziness, headache
- UG: breast pain, spotting/bleeding (intermenstrual, may stop after few cycles)
- Get big: weight gain, fluid retention

Major complications
- Jaundice, liver dysfx
- Thromboembolism, CVS disease (CVA, MI) -> increased risk if high dose/other risk factor
- CA: breast, cervical, liver -> slightly increased risk

COC: contraindications
- Full breastfeeding/non-breast feeding women (within 21 days postpartum)
- Hypertension/co-existing factor for arterial CVS disease
- Hx of VTE, CVA, IHD
- Hx of migraine, CA breast
- Heavy smoker > 35 y.o.
- Major surgery/prolonged immobility

COC: missed pill management
- 1 pill missed -> take when remember -> continue remaining as scheduled
- 2+ pills missed
o Take when remember -> continue remaining as scheduled, PLUS
o Protection for extra 7 days
- Missed in 1
st
week -> emergency contraception
- Missed in 3
rd
week -> skip the 7 day pill-free interval

POP (progesterone-only pill): examples, advantages, disadvantages
Examples
- Cerazette (desogestrel): 3
rd
generation
- Microlutt (levonorgestrel): 2
nd
generation (withdrawn)

Advantages
- No estrogen: no effect on BP, hemostasis, metabolism
- Lactation no interference

Disadvantages
- Menstrual irregularities
- Better timing required
- Fertility returns (immediately, when stop)

Injectables: type, indication
Type
- Progestogen only: depo-provera (the proverb depot: depot medroxyprogesterone acetate)

Indication
- 3-monthly injection
- (Variant: combined monthly injectable = better cycle control)

Injectables: advantages, disadvantages
Advantages
- Highly effective
- Less user-dependent

Disadvantages
- Irregular bleeding
- Weight gain
- Affect bone mineral density (BMD)

Implants: examples, mechanism, advantages, disadvantages
Examples: implanon, jadelle
Mechanism: progestogen released daily

Advantages:
- Highly effect
- Not user-dependent
- Removed 3-5 years later

Disadvantages
- Minor surgical procedure: required for insertion/removal
- Not available in HK

Intrauterine contraceptive device: types
- Copper-containing
- Levonogestrel

Copper-containing IUCD: mechanism, duration, advantages
Mechanism: foreign body reaction in endometrium -> copper inhibits sperm function, transport, gamete viability

Duration: 3-10 years

Advantages:
- Highly effective
- User independent
- Long acting
- No systemic side effects
- Reversible after removal

Copper-containing IUCD: ADR, contraindications
ADR:
- General: Pain, dysmenorrhea; menorrhagia, increased vaginal discharge
- Acute: 1
st
20 days infection risk
- Chronic: translocation, expulsion, perforation
Contraindications:
- Pregnancy (known/suspected), bleeding (undiagnosed vaginal)
- Infection (current genital tract), increased risk of STD
- In endometrium: lesions distorting endometrium, GTD (gestational trophoblastic disease)
- Severe thrombocytopenia

Levonorgestrel IUD: mechanism, duration, advantages, disadvantages, contraindications
Mechanism: a stem releasing levonorgestrel
Duration: 5 years

Advantages: same as copper IUCD

Disadvantages
- Irregular bleeding
- Oligoamenorrhea (long term use)
- General: pain, dysmenorrhea; menorrhagia, increased vaginal discharge
- Acute: 1
st
20 days infection risk
- Chronic: translocation, expulsion, perforation

Contraindications: CA breast + same as copper IUCD

Contraceptive failure: examples, backup
Example
- Rape
- No method used
- Condom failed
- Missed pill

Backup: emergency/postcoital contraception

Emergency contraception: types, examples/indication, advantages/disadvantages
Hormonal
- Examples:
o Yuzpe regimen: high dose estrogen + progestogen
o Levonorgestrel: 1.5 mg (within 3 days of unprotected sex/UPSI)
o Ulipristal: 30 mg (within 5 days of UPSI)
- Disadvantages:
o Side effects: nausea, vomiting (less with levonrgestrel)
o Does not substitute regular contraceptive (cumulative failure rate)
o Does not cause abortion
o Failure rate 1-3% (decrease if taken earlier)

IUCD
- Indication: within 5 days of UPSI
- Advantages:
o After next menstruation: can be continued/removed
o Low failure rate <1%
- Disadvantages:
o Does not cause abortion

Female sterilization: method, disadvantages, alternatives
Method: tubal ligation

Disadvantages
- Permanent (irreversible, may regret)
- Risk of failure
- Ectopic pregnancy
- Surgery required (laparoscopy/minilaparotomy + ax/ risk)

Alternatives
- Sterilization: diathermy, ring (Falope), clip (Filshie), modified Pomeroy ligation
- Contraception
- Male sterilization


Male sterilization: method, advantages, disadvantages
Method: vasectomy

Advantages
- Less risk of failure (<0.1%)
- Simpler
- Safer (done under local anaesthesia)

Disadvantage: not immediately effective

Patients seeking contraception: assessment
- Contraindications
- Reason: spacers, limiters
- Previous: contraceptive use, history (obstetrical, gynaecological, medical)
- Motivation
- Educational, cultural, social backgrounds

Abortion law in HK: termination of pregnancy
- 2 registered doctors required
- Continue pregnancy -> pregnant womans life risked/physical injury/mental injury, greater than if pregnancy
terminated, or
- Substantial risk: child born -> suffer physical/mental abnormality, causing severe handicap

Note: abortion to be carried out in gazetted hospital/family planning association of HK

Pre-abortion counseling
- Be non-judgemental and respect clients informed decision
- Reason(s) for TOP
- Contraceptive history: reason of failure, future plan
- Options: continuation of pregnancy, adoption, TOP
- Psychosocial issues
- Explain method and risks of procedure

Pre-abortion assessment
- Medical, drug and allergy history
- Rhesus type
- Ascertain dating by history, examination +/- USG
- STI screening or empirical prophylaxis

Abortion methods: 1
st
and 2
nd
trimester
First trimester
- Medical method: mifepristone (antiprogesterone) 200 mg peroral -> misoprostol (prostaglandin to induce
labor) 800 ug pervaginal (1-3 days later)
Complete abortion rate > 95%
- Surgical method: suction evaculation (with LA)
More invasive but quicker

Second trimester
- Medical method: misoprostol 400 ug (q3h, 5 dose per day)
- Surgical method: suction evaculation (in case of incomplete abortion/hemorrhage)
Final result: complete abortion rate in 24h: 80-90%

Second trimester abortion: mechanism and complications
Mechanism: induce minilabor -> expulsion of conceptus

Complications:
- Failed/incomplete abortion
- Bleeding
- Infection