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MRCOG PART 2 SBAs and EMQs

MRCOG Part 2, MRCOG 2

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Essay 212 - contraception

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		Posted by Sarwat F. Fri Aug 25, 2006 12:16 am
Effect of contraception on womans subsequent fertility can be explained by individually considering various methods of contraception. Barrier methods of contraception like condoms and diaphragms act by mechanical methods so fertility returns immediately after stopping their use. Oral contraceptive pills are associated with immediate return of fertility. Post pill amenorrhea does not exist as a side effect of pills and warrants investigations as it can be due to any of the causes of secondary amenorrohea. Progesterone only pill are also associated with immediate return of fertility. Intrauterine contraceptive devices are associated with the risk of pelvic infection in 1 % cases which may reduces the chances of conception if severe. It can be associated with ectopic pregnancy which has damaging effects on womans subsequent fertility. IUD can also perforate the uterus if not inserted carefully and penetrate the adjacent structures. This obviously has harmful effects on subsequent pregnancy in the form of risk of uterine rupture or adherent placenta. Long acting progesterone injections are associated with alteration of hormone levels and may delay return of fertility by 6 to 9 months. Use of MIRENA is associated with endometrial thinning and this also interferes with implantation of pregnancy. Progesterone implants are associated with immediate return of fertility after discontinuation of method. Methods like tubal sterilization and vasectomy are meant to be permanent. Reversal of tubal sterilization depends on method used, clips, diathermy etc and surgical expertise available. Reversal is successful in 60 % cases approximately however pregnancy is possible in 40 % cases. There is also a high risk of ectopic pregnancy due to tubal damage. Vasectomy is associated with high success rate of reversal and pregnancy rates as compared to tubal sterilization. There are various moral and psychological issues involved regarding effects of contraception on subsequent fertility.
		Posted by Ismatara B. Fri Aug 25, 2006 07:22 pm
Natural family planning method (such as PERSONA, calender method) and use of barrier contraception (condom, diaphram) do not affect future fertility. Barrier method is protective against sexually transmitted infection (e.g. Chlamydia, gonorrhoea, HIV etc.) which causes pelvic inflammatory diseases, therefore reduces the risk tubal damages and tubal factor infertility. Hence reduces ectopic pregnancy rate. When discontinued, there is immediate return of fertility. The C.O.C. pill is usually associated with the immediate return to normal fertility, but there may be slight delay in return of fertility- mean delay is about 3 months after discontinuation, compared to expected fertility from life tables. There is no difference in fertility after 42 months in nuliparous and 30 months in multiparous. COCP itself is not associated with amenorrhoea. 1% of women develop ?Post-pill amenorrhoea?. ?Post-pill amenorrhoea? is not a diagnosis. Any post pill delay in the return to normal fertility and mensrtuation is dependent upon the age of the woman, underlying cause like pituitary ovarian dysfunction and the duration of use. Underlying causes were masked by regular withdrawl bleeding. On the other hand COCP protects against PID, hence reduces tubal factor infertility. There is no increase in the incidence of secondary amenorrhoea in previous pill users with the progestogen only pill. There is also immediate return of fertility and normal ovulatory cycle. Progestogenic implants (e.g. Norplant) have no long term effect on subsequent fertility. Most women restart normal ovulatory cycles and menstruation within 1 month after removal of Norplant or Implanon. Injectable progestogen preparations (Depo-provera) are associated with a delay in return of fertility of about 8 months after the last injection. The delay may be as much as 24 months. But 85% women conceive within 24 months. The delay does not increase with duration of use. The intrauterine device (IUCD) is associated with an increased incidence of pelvic inflammatory disease in the first 20 days after insertion due to sexually transmitted disease. This may cause tubal factor infertility. The decrease in the fertility rate is largely dependent upon the lifestyle of the user than the IUCD itself. Hence increased incidence of ectopic pregnancy rate, which is less than not using any contraception but more than COCP user. Related ectopic pregnancy treatment may further reduce fertility. There is also risk of uterine perforation during insertion which will adversely affect in future fertility. Otherwise fertility return immediately after removal of IUCD. The levonorgestrel intrauterine system (Mirena) does not appear to be associated with lowering of fertility rates. LNG IUS has lower risk of PID, hence ectopic pregnancies compared to copper IUDs. Progesterine induced endometrial changes usually resolves within 30 days of removal. Here is also risk of perforation during insertion with adverse effect in fertility. Sterilisation-Bilateral tubal ligation is a permanent method of contraception. It is done in women who donot want future pregnancy. The life time failure rate is 1:200. Reversal is possible, tubal patency rate is 70-80% and pregnancy rate is 40-60%. But is associted with increased incidence of ectopic pregnancy. Male sterilisation (vasectomy) does not affect woman?s fertility.
		Posted by Ebeinheizer S. Fri Aug 25, 2006 07:33 pm
An ideal contraception should have no affect on subsequent fertility. However, individual sexual behaviour while on contraception may cause reduction in subsequent fertility. This has to be highlighted during pre-contraception counseling as part of sexual health. Having multiple sexual partners and unprotected sex can predispose to sexually transmitted infections (STI e.g. Chlamydia, Gonorrhoea) which may cause Pelvic Inflammatory Disease (PID) leading to tubal damage and adhesions which are proven causes of subfertlity. However, condoms give some protection against this. Combined oral contraceptive pills (COCP) are most commonly used in the UK. It also has alternate preparations such as patches, injectables and vaginal rings. All of them acts by inhibiting ovulation. Upon cessation, there are no effects on subsequent fertility. However, the woman might suffer menstrual/ovulatory irregularities for a few cycles after stopping COCP which can reduce her fertlity. She should be warned about this. However, any irregularities beyond 6-12 months, even failure to conceive, need to be investigated as COCP usage might have masked underlying menstrual/ovulatory disorders. “Post pill amenorrheoea” is a myth which should be dispelled. Progestogen only pills (POP) such as Norethisterone and Desogestrel acts mainly by inhibiting sperm penetrance through thickening of cervical mucosa. However, 40-60% are known not to ovulate while on POP. Upon stopping POP, fertility is restored with no effect. Similar rule applies to Implanon. This is because the progestogenic affect of cervical mucosa thickening and inhibition of tubal ciliary propulsion of ovum is removed. The natural oestrus cycle resumes upon cessation and there are no adverse effect on fertility. Depo Medroxy Progesterone Acetate (DMPA) is a 3 monthly progestogen injection. Its mechanism of action is similar to POP but stays longer in the woman’s system due to binding with her adipose tissue. Upong stopping DMPA, fertility is not restored immediately due to the fat binding properties. Sustained release is known to occur and it takes time for the medroxy progesterone to be cleared by her system. As such, DMPA is not suitable for someone who wishes temporary contraception for a fixed period of time only. Intra uterine contraceptive device (IUCD) acts mainly by creating a hyperinflammatory environment in the endometrial cavity even though the exact mechanism is not known. This occurs only as long as the IUCD is in situ. Thus, upon removal, fertility is restored and not impaired. However, IUCD is associated with an increased risk of PID as compared to other contraceptions which means her risk for subfertlity due to tubal damage or adhesions would be higher. Levonogestrel intra-uterine system acts by local release of levonogestrel which thins the endometrium, increases cervical mucosa thickening and prevents implantation. It is also shown to reduce the risk of PID associated with IUCD. It also does not have any effect upon fertility. Barrier and natural methods of contraception have no effect on fertility. Sterilization are permanent methods of contraception which are “irreversible”. Sterilization is usually done for couples who have completed family. However, reversal of sterilization if fertility is desired is possible. However, it is associated with risks of failure and ectopic pregnancy for the woman. It is more successful for the male. However, the overall successful preganacy after reversal is poor.
		Posted by Aroosha B. Fri Aug 25, 2006 09:36 pm
Return of fertility after discontinuation of contraception depends upon type of contraceptive method and their mode of action, as regards COCP there is ultimate return of fertility ,it may take three months .seventy %of woman ovulate in first cycle and 98 % in third cycle after discontinuation of COCP.moreover use of COCP has beneficial affects on COCP as it makes cervical mucous thick so it decreases the risk of PID and its subsequent fertility , it also prevents ectopic pregnancy which is favouable in relation to future fertility.one % of patients do have post pill ammenorhea which is not related to dose , formulation , or duration of COCP. Most of these woman have previously have endocrinological disorder (Pof , Pco ,Hyperprolactinemia.)And these woman use COCP for management of these problems. It also occurs in those who lose wt, while using COCP, anyhow if post pill amenorrehoa occur history and investigation should include above mentioned d/d. POP: their mode of action is that they increase thickness of cervical mucous and 50 % of patients continue to ovulate while taking them and ovulation is suppressed in 10 to 20%. So on stopping this there is immediate return of fertility and as it makes cervical mucous thick it is beneficial in preventing PID but it does slightly increases the incidence of ectopic pregnancy as compared to COCP which can decrease the future fertility but this risk is not increased in general population who are not using contraceptive. Depoprovera:it is highly affective contraception as it suppreses ovulation but return of fertility is delayed after discontinuation due to its crystalline form which breaks down slowly in the tissue but 70 % of the women conceive after one yearof discontinuation and 92% after two years . This delay does not increase with increased duration of its use . Subdermal implants: include Norplant and Implanon which mainly inhibit LH surge and subsequent ovulation . Most women resume normal ovulatory cycle during fist month of its removal and both do not have long term affect on future fertility , IUCD: this is also extremely effective and reliable method of reversible contraception but there are concerns as regards future fertility . It increase the risk of PID in first 20 days after insertion .but this risk is more in those who are not in stable relationship and have recurrent and severe attack of PID.so careful selection of patient can decrease this risk . Another concern is that it slightly increases the risk of ectopic pregnancy in comparison to COCP but overall its risk is not increased in general population . LNG IUS: main mode of action is suppression of endometrium and subsequent implantation , fertility is immediately reversible . Moreover it also dereases the risk of PID and ectopic pregnancy preserving future fertility . Emerergency contraception : has potential to disrupt ovulation in the cycle in which it is taken, but may be associated with short delay in the return of regular cycle and subsequent contraception . Natural method /barrier method:are followed by immediate return of fertility after discontinuation . Moreover barrier method decreases the risk of PID and and subsequent infertility, Sterlization: are permanent method of contraception . Female sterilization is associated with failure of 1 in 200 reversal of sterilization is successful in 60 to 80 % of patients while pregnancy occurs in about 60 % of patients . Male sterlisation is assocated with failure rate of 1 in 2000 but if patients want reversal it is successful in 90 % of patients but pregnancies occur in only 40 to 60 % of patents due to development of antisperm antibody.
		Posted by Freha Z. Sat Aug 26, 2006 05:41 am
Contraceptive use decreases the risk of unsafe abortion and its complications which may significantly compromise a women,s future fertility. After stopping combined contraceptive pills the return of ovulation is prompt, 70% ovulate in first cycle, 98% by their third cycle. It reduces the risk of ascending infection and PID. Risk of ectopic is also reduced due to contraceptive effect of pills. Additionally women who conceive after discontinuing pills have no increase in pregnancy loss or ectopic pregnancy. Modern low dose formulations having less androgenic progestogens take away the risk of masculinization of female fetus. However, 1% women experience amenorrhoea after stopping pill. It may be due to underlying endocrinological abnormalities including Polycystic ovaries, premature ovarian failure, hyperprolactinaemia and cessation of pills merely unmask the underlying condition Progestrone only pills effects are rapidly reversible and have no effect on future fertility. However they do not provide same protection against ectopic pregnancy as combined pills do. Implanon is long acting reversible implant. It exers its contraceptive effects by inhibiting ovulation. It is associated with return of ovulation within six weeks. Depot medroxy progesterone acetate is long acting intramuscular injection every 12 weeks. Following the final injection ovulation returns after 4-5 months and return of fertility may take upto 24 months. Hormonal emergency contraception disrupts ovulation in the cycle in which it is taken, so it may be associated with a short delay in return to a regular cycle and subsequent conception. The intrauterine contraceptive device is reliable method of reversible contraception. But it is associated with increased incidence of pelvic inflammatory disease leading to decrease in fertility but it is largely dependent on the life style of the user than IUD itself. Therefore careful patient selection is important ensuring that women at increased risk of sexually transmitted infection are not offered this method as first choice. Pre-insertion bacteriological screening may be appropriate in young nulliparous women or at time of potcoital insertion. Risk is increased by increase in risk of ectopic. Mirena (LNG-IUS) has additional beneficial effect in protecting against ascending genital tract infection by hormonal action. Moreover, risk of ectopic is lower compared to Cu-IUD. Barrier and natural methods of contraception are associated with no loss or delay of fertility. Barrier method reduces the risk of PID by reducing sexually transmitted infections. Therefore subsequent fertility rates are likely to be enhanced compared with women not using contraception. Permanant methods like vasectomy and tubal ligation are irreversible methods. Therefore Pre-steriliztion counselling should ensure that they understand these as permanant methods and know about alternative methods of contraception. Failure rate of tubal ligation is 1 in 200. Reversibilty is an option but is operator dependent. Failure rate of vasectomy is 1 in 2000 and return of fertility even after surgery is limited by formation of antisperm antibdies.
		Posted by neera B. Sun Aug 27, 2006 03:34 pm
Barrier methods do not affect a womens subsiquent fertility. There is prompt return of fertility on stopping them. The term post-pill amenorrhoea with combined OC pill is a misnomer. The pill simply masks the amenorrhoea by causing withdrawl bleeding evry month. If amenorrhoea persists for over 6 months after stopping the pill, it should be investicated. There is no adverse effect of COC pill on womens fertility. The progesterone only pill and implants have no effect on subsiquent fertility and there is immediate return of fertility on stopping them. Depot progesterone preprations cause amenorrhoea, on average for eight months after stpping them, but this may extend to 24 months. Depot medroxy progesterone acetate is more likely to cause prolonged amenorrhoea than norethisterone enanthate. Intrauterine contraceptive devices cantaining copper are associated with increased risk of PID. Although they decrease the incidence of both intrauterine pregnancy and ectopic; if a pregnancy occurs with IUCD, it is more likely to be ectopic ( 1 in 20 ) compare to non user ( 1 in 100 ). If PID dovelops, fertility may be decreased; otherwise there is prompt return of fertility. The LNG-IUS removal promty returns fertility. Unlike copper containing IUCD, the irsk of PID and ectopic is not relatively increased. Female sterilisation is a permanent procedure but failure rate of 1 in 200 exists. Even if reversal is desired, only 60 to 70% success rate is attained. The patient must be councelled, leaflets given and allowed to make informed choice.
		Posted by Samir A. Wed Aug 30, 2006 09:38 pm
Combined oral contraceptive pills (COCP) is associated with ultimate return of fertility.However post pill delay happens with COCP. This related to age of the woman and duration of use. for instance a woman who use COCP for 20 years and discontinue it at tge age of 40 is expected to have delay of return of fertility if compared with a woman who discontinue COCP at the age of 25 after 5 years of use. COCP does not cause secondary amenorrhoea. If the woman has post pill amenorrhoea more than 6 months, we should investigate for the cause, since withdrawal bleeding of the pills may masc a pathological cause(hyper prolactinaemia). Fertility return immediately after discontinuation of low dose progestogen pills (POP). Women using Implants, resume normal ovulatory cycles after one month of removal of the implants. Ther no long term effects on future fertility. Injectable contraception;Depo provera is associated with delay of conception for 9 months after last injection in most of users and the delay does not increase with the duration of use. However 85% of women could achieve pregnancy within 24 months of discontinuation. IUCD (Intra uterine contracetive device) increases (2-4 fold) the risk of PID (Pelvic inflammmatory disease) in the first 20 days of insertion, which might csuse tubal disease and consequantly ectopic pregnancy and tubal infertility. Later on the incidence of PID is dependant on the woman life style. PID in such case is commonly a STD. Eventhouh the risk of ectopic pregnancy is much lower than in non contraception users, but still higer than COCP users. LNG-IUS (Levonorgestrel intratterine system device) deos not appear to be associated with lower fertility rates. This may be due to lower incidence of PID and ectopic pregnancy. Female sterilisation is deemed to be a permanent method of contraception. However women wish to reverse the procedure can achieve 70-80% reversal of tubal patency through tubal microsurgery with pregnancy rate of 40-50%. Vasectomy could also be reversed within 5 years with pregnancy rate of 50%. Barrier methods (condoms, diaphragms, cervical caps) and Natural methods are associated with immediate return of fertility after discontinuation.