Topic: Infertility marriage. Family planning icon

Topic: Infertility marriage. Family planning




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Topic: Infertility marriage. Family planning.

  1. Topicality: to know the causes preventing physiological pregnancy is very important, because frequency of infertile marriages increases from year to year and today is constitutes10-15% and only 30% of them are curable. Timely diagnostics and correctly elaborated algorithm of treatment of infertility is the pledge to stabilize demographic situation in Ukraine.

  2. Number of hours: 4.

  3. Educational objectives: to study the causes of infertility in marriage (frequency, etiology, clinical manifestation, methods of treatment.) To deepen knowledge concerns prevention of infertility and organization of family planning in the work of a district doctor.

    1. To know: a=II

  1. What dоes the notion «infertile marriage» comprise?

  2. What are the kinds of infertile marriage?

  3. Qualitative and quantative indices of fertile sperm.

  4. Causes of female infertility.

  5. Diagnostic methods of tubular infertility.

  6. Diagnostic methods of endoscopic infertility.

  7. Algorithm of examination of a family couple with immunologic infertility.

  8. Indications and contraindications for surgical treatment of tubular infertility.

  9. Indications for extracorporal fertilization.

  10. Therapeutic principles of endocrine infertility.

3.2 To be able to:

1. Estimate the results of examination of ovarian functional state.

2. Estimate the results of laboratory, cytological, X-ray methods of examination, USD.

3. Make up a plan of examination of a patient with suspected tubular genesis of infertility.

4. Choose anamnesis data indicating the cause of infertility.

5. Perform examination of the uterine cervix, vaginal examination and make the initial diagnosis.

6. Make up a plan of treatment of endocrine infertility depending on its genesis.

7. Interpret the results of spermogram.

^ 3.3 To master practical skills: a=III

  1. Anatomy of the female reproductive organs.

  2. The main conditions of fertility and fertilization.

  3. The main and additional special methods of examination, their diagnostic value.

  4. Examination methods of a functional state of the ovaries.

  5. Neuro-endocrine regulation of the menstrual cycle.

  6. Normal and pathological results of laboratory examination methods (blood, urine, vaginal discharge, etc.).



Summary

Infertility  :  Etiology, Diagnostic Evaluation, Management, Prognosis




^ KEY TERMS AND DEFINITIONS

Artificial Insemination

Method to place sperm in the female reproductive tract by means other than sexual intercourse. If the sperm are from the husband, the technique is called artificial insemination husband (AIH). If the sperm are from another man, the method has been called artificial insemination donor (AID). Other terms are donor insemination and therapeutic donor insemination (TDI).

^ Assisted Reproductive Technology

Various techniques utilized to increase fecundability by nonphysiologic methods of enhancing probability of fertilization. Categories include in vitro fertilization, gamete intrafallopian tube transfer, zygote intrafallopian tube transfer, and tubal embryo transfer.

Asthenospermia

Loss or reduction of the motility of the spermatozoa.

Azoospermia

Absence of sperm in the semen.

Clomiphene Citrate

A weak synthetic estrogenic compound with three benzene rings given orally to induce ovulation in anovulatory women with circulating estradiol levels more than 40 pg/mL.

^ Controlled Ovarian Hyperstimulation (COH)

Inducing development of more than one dominant follicle with pharmacologic agents, usually clomiphene citrate or gonadotropins, also called superovulation or multiple follicular recruitment (MFR). COH is usually combined with intrauterine insemination to treat unexplained infertility.

Fecundability

Probability of conception occurring in a population of couples in a given period of time, usually 1 month.

Fimbrioplasty

Surgical technique of removing adhesions between fimbrial fronds of the partially occluded distal end of the oviduct.

^ Gamete Intrafallopian Transfer (GIFT).

Placement of human ova and sperm into the distal end of the oviduct.

Hamster Egg Penetration Assay (Sperm Penetration Assay)

Test of the fertilizing ability of human sperm based on their ability to penetrate zona-free hamster ova.

^ Human Menopausal Gonadotropin (HMG)

Formulation made up of equal amounts of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) derived from urine obtained from postmenopausal women. The injectable agent is used to stimulate follicular development in both anovulatory and ovulatory women.

Several urinary extracts are available including one with proportionality greater FSH activity. Recombinant (pure) FSH is often used and recombinant (pure) LH is also available as a supplement.

^ Hysterosalpingogram (HSG)

Fluoroscopic and radiographic visualization of the interior of the female upper genital tract after instillation of radiopaque dye.

Intracytoplasmic Sperm Injection (ICSI)

Technique by which a single spermatozoon is injected into the cytoplasm of an ovum.

Infertility

Inability of couples of reproductive age to establish a pregnancy by having sexual intercourse within a certain period of time, usually 1 year. Infertility is considered primary if the woman has never been pregnant and secondary if it occurs after one or more pregnancies.

^ Intrauterine Insemination

Placement of spermatozoa that have been separated from the seminal fluid into the endometrial cavity through a small catheter.

In Vitro Fertilization

Fertilization of human ova by sperm in a laboratory environment.

^ Luteal Phase Deficiency (Inadequate Luteal Phase)

Deficient progesterone secretion or action resulting in a delay of normal endometrial development.

Microsurgery

Operative technique using magnification and fine, nonreactive suture material.

^ Oligozoospermia (Oligospermia).

Presence of fewer than 20 million sperm per milliliter of semen.

Ovarian Hyperstimulation Syndrome (OHSS)

Ovarian enlargement to a diameter of more than 6 cm as a result of stimulation of multiple follicles. In the mild form there is abdominal pain, distention, and weight gain. In the moderate form ovarian enlargement is more than 10 cm in diameter with ascites, nausea, and vomiting. Severe OHSS is associated with hemoconcentration, oliguria, and elevated serum creatine. Pleural effusions and ascites can be present; OHSS becomes critical when hypercoagulability and hypotension occur. This condition may be fatal.

^ Postcoital Test

Examination of the cervical mucus to evaluate the presence of sperm several hours after sexual intercourse.

Pronuclear Stage Tubal Transfer (PROST) or Zygote Intrafallopian Transfer (ZIFT)

In vitro fertilization with transfer of the zygote to the oviducts by transabdominal cannulation.

^ Salpingitis Isthmica Nodosa

Diverticula of the endosalpinx in the muscularis of the isthmic portion of the oviduct.

Salpingolysis

Removal of adhesions attached to an oviduct that appears normal on gross inspection.

Salpingostomy

Surgical creation of a new opening of a completely occluded distal end of the oviduct.

^ Semen Analysis

Quantitation of various parameters of a recently ejaculated semen specimen analyzed after liquefaction has occurred.

Spinnbarkeit

Property of elasticity (distensibility) of cervical mucus.

Teratozoospermia

Greater-than-normal (50%) incidence of abnormal forms of sperm in semen analysis.

^ Treatment-Independent Pregnancy.

Infertile women conceiving without use of infertility therapy.

Tubal Embryo Transfer (TET) or Tubal Embryo Stage Transfer (TEST)

Same as ZIFT, except additional incubation to embryo stage occurs before transfer to the oviducts.

^ Unexplained Infertility

The diagnosis of an infertile couple when ovulation and tubal patency, as well as a normal semen analysis, are all present.

Testicular Sperm Extraction

Retrieval of sperm from the testis by biopsy or aspiration from men with azoospermia due to obstruction of the vas deferens or epididymis (obstructive azoospermia) or without such obstruction (nonobstructive azoospermia). The sperm are injected into ova retrieved by follicle aspiration by the ICSI procedure.

The term infertility is generally used to indicate that a couple has a reduced capacity to conceive as compared with the mean capacity of the general population. In a group of normal fertile couples, the monthly conception rate, or fecundability, is about 20%. This figure is important for all couples seeking fertility to know, because it will alleviate unrealistic expectations of immediate success with various therapies, which can only approach 20% per cycle (with the exception of in vitro fertilization/embryo transfer [IVF-ET]). For most couples the correct term should be subfertility, suggesting a decreased capacity for pregnancy but not an impossible feat.

^ KEY POINTS

  

•   

In 1995 about 10% of all U.S. couples with women in the reproductive age group were infertile—6.2 million women.

  

•   

The incidence of infertility steadily increases in women after age 30.

  

•   

Among fertile couples who have coitus in the week before ovulation, there is only about a 20% (monthly fecundability of 0.2) chance of developing a clinical pregnancy in each ovulatory cycle.

  

•   

In about half of fertile couples attempting to conceive the woman will become pregnant in 3 months, 75% in 6 months, and 90% at the end of 1 year.

  

•   

Infertile couples who conceive do not have higher rates of spontaneous abortion or perinatal mortality than age-matched control subjects.

  

•   

In the United States approximately 10% to 15% of cases of infertility are caused by anovulation, 30% to 40% by an abnormality of semen production, 30% to 40% by pelvic disease, and 10% to 15% by abnormalities of sperm transport through the cervical canal. About 10% to 20% of cases are unexplained.

  

•   

The primary diagnostic tests for infertility are documentation of ovulation, semen analysis, and hysterosalpingogram (HSG).

  

•   

The basal body temperature (BBT) increases when circulating levels of progesterone increase, and a sustained increase of BBT occurs following ovulation.

  

•   

A sustained rise in BBT or a serum progesterone level greater than 5 ng/mL is presumptive evidence of ovulation.

  

•   

A midluteal-phase serum progesterone level above 10 ng/mL is an indication of adequate luteal function.

  

•   

A high percentage of fertile men will have at least one abnormal parameter in their semen analysis.

  

•   

In women with a normal HSG, a hysteroscopy is unnecessary because it will not detect additional abnormality.

  

•   

Other diagnostic tests for infertility, including (1) measurement of serum prolactin and TSH in ovulatory women, (2) a late luteal-phase endometrial biopsy, (3) immunologic tests to detect sperm antibodies, and (4) bacterial culture of cervical mucus and semen.

  

•   

There is no evidence that treatment of an abnormality in the tests just listed significantly improves pregnancy rates compared with withholding therapy.

  

•   

Of all the causes of infertility, treatment of anovulation results in the greatest success.

  

•   

When ovulation is induced with clomiphene citrate and no other causes of infertility are present, conception rates over time are similar to those of a normal fertile population.

  

•   

Discontinuation of therapy is the major reason for the reported difference in ovulation and conception rates in anovulatory women treated with clomiphene.

  

•   

More than 90% of women with oligomenorrhea and 66% with secondary amenorrhea and E2 levels of 40 pg/mL or higher will have presumptive evidence of ovulation following clomiphene therapy.

  

•   

When conception occurs after clomiphene treatment in anovulatory women, the incidence of multiple gestation is increased to about 8%, nearly all of them being twin gestations. The incidences of clinical spontaneous abortion, ectopic gestation, intrauterine fetal death, and congenital malformation are not significantly increased.

  

•   

Formation of ovarian cysts is the major side effect of clomiphene treatment.

  

•   

About 5% to 10% of women treated with the individualized, graduated, sequential regimen of clomiphene citrate fail to ovulate with the highest dosage.

  

•   

Treatment of anovulation with gonadotropin effects an ovulatory rate of about 100%.

  

•   

The pregnancy rate per cycle with gonadotropins is similar to that following clomiphene therapy (22%).

  

•   

The incidence of spontaneous abortion after HMG therapy is high (25% to 35%), and clinically detectable ovarian enlargement occurs in about 5% to 10% of treatment cycles.

  

•   

If GnRH is used for ovulation induction it needs to be administered in a pulsatile manner at intervals of 1 to 2 hours.

  

•   

For women with polycystic ovaries who do not ovulate following administration of clomiphene citrate, partial ovarian destruction by electrocautery or laser through the laparoscope is effective in inducing ovulation.

  

•   

Pregnancy rates for oligospermia following intrauterine insemination are in the 25% to 35% range.

  

•   

Semen donors need to be carefully screened to be certain that they are in good health, do not have a potentially inherited disorder, and will not transmit an infectious agent in the semen.

  

•   

Because antibodies to HIV may not develop for several months after infection, it is recommended that all donor insemination be performed with frozen sperm that has been stored for at least 6 months at which time negative antibodies to HIV should be observed in the donor before the sperm is used for insemination.

  

•   

The prognosis for fertility after tubal reconstruction depends on the amount of damage to the oviduct as well as the location of the obstruction.

  

•   

If both proximal and distal obstructions of the oviduct exist, intrauterine pregnancy is uncommon, and operative reconstruction should not be performed, IVF is the best therapy.

  

•   

Women with pelvic tuberculosis should be considered sterile, and no tubal reconstructive procedures should be attempted. IVF may be attempted if the endometrial cavity is not infected.

  

•   

Overall conception rates following salpingostomy are in the 30% range, with a high percentage (about one fourth) being tubal pregnancies.

  

•   

The pregnancy rate after salpingolysis and fimbrioplasty for partial distal obstruction is about 65%.

  

•   

Unlike the results of distal tubal reconstruction, the use of microsurgery has improved intrauterine pregnancy rates for proximal tubal disease.

  

•   

Proximal tubal obstruction is now usually treated by cannulation of the oviducts with catheters or balloons placed under hysteroscopic visualization.

  

•   

The benefit of second-look laparoscopy after tubal surgery has not been established.

  

•   

No medical therapy for endometriosis has proved to increase pregnancy rates compared with no treatment.

  

•   

Pregnancy rates for women with mild endometriosis can be increased with the use of controlled ovarian hyperstimulation and intrauterine insemination but not with danazol.

  

•   

About 65% of women with mild endometriosis and no other cause of infertility conceive without treatment. With moderate or severe disease, pregnancy rates with expectant management are 25% and 0%, respectively.

  

•   

Conception rates for women treated surgically have been reported to be in the 50% to 60% range for those with moderate endometriosis and 30% to 40% for those with severe endometriosis.

  

•   

About half of infertile women with myomas conceive after myomectomy.

  

•   

Luteal-phase deficiency, as currently diagnosed histologically, is probably a normal biologic variant and not a true cause of infertility.

  

•   

No data conclusively demonstrate that the finding of antisperm antibodies in either member of the couple is a cause of infertility.

  

•   

In women with unexplained infertility the use of controlled ovarian hyperstimulation (COH) and intrauterine insemination (IUI) yields monthly fecundity rates of 10% to 15%. Therefore COH and IUI should be the initial treatment for women who ovulate, have patent oviducts, and whose male partner has at least 5 million motile sperm in the ejaculate.

  

•   

For IVF with and without ICSI the delivery rate per cycle in which ova are retrieved is as high as 40% depending on the age of the woman.

  

•   

The rate of pregnancy following IVF is directly related to the number of embryos placed in the uterine cavity.

  

•   

The pregnancy rate per cycle of IVF remains relatively constant for about six cycles after which it declines. After six cycles the cumulative pregnancy rate is about 60%.

  

•   

There is a high spontaneous abortion rate (about 30%) for pregnancies after IVF.

  

•   

If an infertile couple fails to conceive after 2 years of therapy, they should be informed the chances for conception are remote.

  

•   

The optimal treatment for all causes of sperm abnormalities is ICSI. With this technique, pregnancy rates per cycle are similar to that of IVF performed for other causes of infertility.




^ INCIDENCE OF INFERTILITY

Results from the three U.S. National Surveys of Family Growth performed under the direction of U.S. government agencies provide information about infertility in this country. Analysis of the data obtained from the surveys performed in 1982, 1988, and 1995 indicate that the proportion of U.S. women ages 15 to 44 with impaired fecundity increased from 8% in 1982 and 1988 to 10% in 1995, a 20% rise. It was estimated that the number of women with impaired fecundity in the United States increased from 4.6 million to 6.2 million between 1982 and 1995, a 35% rise. Most of this increase occurred among nulliparous women in the oldest age group (35 to 44) due to women of the Baby-Boom generation reaching this age. Many in this group had delayed their childbearing. The percentage of women with impaired fecundity seeking medical assistance for this problem remained stable, about 44% between 1988 and 1995. However because more women had impaired fecundity there was a 30% increase in women who utilized medical help for this problem in the United States, an increase from 2.1 to 2.7 million women.


Family Planning  :  Contraception, Sterilization, and Pregnancy Termination


^ KEY TERMS AND DEFINITIONS

Contraception.

The prevention of pregnancy.

Contraceptive Failure Rate.

Pregnancy rates with various types of contraceptives at different intervals, usually years. This rate is frequently expressed as number of pregnancies per 100 women at 1 year or per 100 woman-years.

^ Contraceptive Patch.

An adhesive matrix 20 cm2 patch containing ethinyl estradiol and norelgestromin that is placed transdermally by the user. The steroids are delivered into the circulation for 1 week.

^ Contraceptive Ring.

A flexible soft transparent ring-shaped device containing etonogestrel and ethinyl estradiol that is placed in the vagina. The steroids are delivered into the circulation at a constant rate for 3 weeks.

^ Emergency Contraception.

Administration of steroids or insertion of a copper IUD within 3 to 7 days after a single episode of unprotected, midcycle sexual intercourse.

Induced Abortion.

Intentional medical or surgical termination of pregnancy before 20 weeks' gestation. Also called elective pregnancy termination if performed for the woman's desires or therapeutic abortion if performed for reasons of maintaining the mother's health.

^ Intrauterine Device (IUD).

A small device, usually made of plastic with or without copper or a progestin, placed into the endometrial cavity to provide an effective method of contraception. Also called intrauterine contraceptives (IUC) or intrauterine systems (IUS).

^ IUD Event Rates.

Incidence of adverse events, such as expulsion, removal for medical reasons, and pregnancy, at various times after insertion of an IUD.

Implant.

An ethylene vinyl acetate rod containing etonogestrel that is placed in the subcutaneous tissue of the upper arm and provides excellent contraceptive effectiveness for 3 years.

Life Table Method.

An actuarial technique for determining rates of occurrence of events, such as pregnancy and discontinuation, at various intervals after starting any type of contraceptive.

^ Perfect Use Effectiveness.

The rate of effectiveness when the contraceptive method is always used correctly. Previously called method use.

Natural Family Planning.

Periodic abstinence from intercourse during the periovulatory time of the cycle. Also known as rhythm.

Microinsert.

A device that is inserted transcervically through a hysteroscope into the proximal portion of the oviduct to provide permanent tubal occlusion.

^ Oral Contraceptive Steroids (OCs).

Formulations of various synthetic progestins usually combined with a synthetic estrogen that are ingested orally to prevent conception. When the progestin is combined with an estrogen the formulation is called a combination oral contraceptive (COC). Oral progestin tablets without estrogen are called minipills.

^ Pearl Index.

A nonactuarial method used for determining the pregnancy (failure) rate of any contraceptive technique:



Progestin.

A class of sex steroids having progestational activity. The terms progestogen and gestagen are synonymous.

Spermicide.

A local contraceptive containing the surfactant nonoxynol 9, which is toxic to sperm.

Sterilization.

Prevention of pregnancy by vasectomy or tubal interruption or blockage. This method of contraception should be considered permanent.

^ Typical Use Effectiveness.

Overall effectiveness rate in actual use for a specific contraceptive method. Previously called use effectiveness.

Reversible contraception is defined as the temporary prevention of fertility and includes all the currently available contraceptive methods except sterilization. Sterilization should be considered a permanent prevention of fertility even though both vasectomy and tubal interruption can usually be reversed by a meticulous surgical procedure. The reversible methods are also called active methods, and sterilization is also called a terminal method. A perfect method of contraception for all individuals is not currently available and probably will never be developed. Each of the various methods of contraception currently available has certain advantages and disadvantages. Therefore, when giving advice about contraception, the clinician should explain to the couple the advantages and disadvantages of each method, so they will be fully informed and can rationally choose the method most suitable for them. Because no reversible contraceptive method other than the condom has yet been developed for use by the male, the contraceptive provider generally counsels the female partner and should inform her if there are medical reasons that contraindicate the use of certain methods and offer her alternatives.

^ KEY POINTS

  

•   

In 2002, of the 62 million women in the United States ages 15 to 44 years, approximately one third were not at risk for pregnancy, and 62%, 38 million, were using a method of contraception. About 7% of women of reproductive age were sexually active and not using any contraceptive.

  

•   

In 2001, there were about 6.4 million pregnancies in the United States. There were 4 million births and about 1.3 million elective abortions. Half of all pregnancies were unintended. About 20% of all pregnancies were electively terminated.

  

•   

Of women ages 15 to 44 in the United States in 2002, male and female sterilization were used by 22%, oral contraceptives by 19%, male condom by 11%, the progestin injection by 3%, and the IUD by 1.3%.

  

•   

Typical and perfect use failure rates in the first year of use range between 5% and 27% for coitus-related methods beween 0.3% and 8% for oral contraceptives (OCs) and 0.3% to 3% for the injection. The IUD and implants have typical use failure rates less than 1%.

  

•   

Contraceptive failure rates are increased in inverse relation to the user's age, level of education, and socioeconomic class.

  

•   

Pregnancy results from failure of spermicide use are not associated with an increased risk of fetal malformations.

  

•   

The active ingredient in spermicides is a surfactant, usually nonoxynol 9, which immobilizes or kills sperm on contact.

  

•   

Barrier techniques reduce the rate of transmission of sexually transmitted diseases, both bacterial and viral.

  

•   

The most effective type of periodic abstinence is the symptothermal method.

  

•   

OC formulations in the United States consist of varying dosages of one of the following progestins: estranes: norethindrone, norethindrone acetate, ethynodiol diacetate, or gonanes: norgestrel (or its active isomer, levonorgestrel), desogestrel, norgestimate, or a spironolactone derivative, drosperinone and either of two estrogens, ethinyl estradiol or ethinyl estradiol-3-methyl ether, also called mestranol.

  

•   

A given weight of norgestrel or the other gonanes has 5 to 10 times more progestational activity than the equivalent weight of norethindrone, whereas norethindrone acetate and ethynodiol diacetate are similar in potency to norethindrone.

  

•   

Metabolic effects of the estrogen component of OCs include an increase in serum globulins that have a thrombophilic effect and altering of the lipid profile to increase triglycerides and HDL cholesterol and lower LDL cholesterol.

  

•   

Metabolic effects of the progestin component of OCs include peripheral insulin resistance and lowering HDL cholesterol and raising LDL cholesterol.

  

•   

Ethinyl estradiol is approximately 1.7 times as potent as an equivalent weight of mestranol.

  

•   

No significantly increased risk of breast cancer occurs among current or former users of OC or in various high-risk subgroups of OC users.

  

•   

OC users have an increased risk of developing invasive cervical cancer, particularly adenocarcinoma, compared with users of no contraception, but a causal relation has not been established.

  

•   

The rate of return of fertility after stopping OCs is delayed, but eventually the percentage of women who conceive after stopping all methods of contraception, including OCs, is the same.

  

•   

Babies born to women who discontinue OCs or who conceive while ingesting OCs have no greater incidence of any type of birth defect.

  

•   

All OC formulations with less than 50 ?g of estrogen increase the risk of venous thrombosis and embolism three- to fourfold.

  

•   

A significantly increased risk of developing MI occurs only in current OC users older than age 35 who smoke.

  

•   

Users of low-dose OCs do not have a significantly increased risk of developing ischemic or hemorrhagic stroke if they do not smoke or have hypertension.

  

•   

The cause of MI in older OC users who smoke is arterial thrombosis.

  

•   

Adverse effects produced by the estrogenic component of OCs include nausea, breast tenderness, fluid retention, temporary increase in blood pressure, thrombosis, changes in mood, and chloasma. Progestins produce certain androgenic adverse effects, including weight gain, nervousness, depression, tiredness, and acne, as well as failure of withdrawal bleeding or amenorrhea.

  

•   

In an ovulatory cycle the mean blood loss during menstruation is approximately 35 mL, compared with 20 mL for women ingesting OCs.

  

•   

OC users are about half as likely to develop iron deficiency anemia as are control subjects.

  

•   

OC users are significantly less likely to develop menor-rhagia, irregular menstruation, or intermenstrual bleeding than nonusers.

  

•   

The risk of developing endometrial cancer, as well as ovarian cancer, in OC users and former users is only half that in control subjects. OC users also have a 50% reduction in the incidence of benign breast disease.

  

•   

OC users have approximately 50% less dysmenorrhea and about 40% less premenstrual disorders than do control subjects.

  

•   

Functional ovarian cysts occur less frequently in OC users than in nonusers if they use monophasic, but not multiphasic, formulations.

  

•   

Prior use of OCs does not affect mortality rates in women.

  

•   

OCs reduce the clinical development of salpingitis (PID) in women infected with gonorrhea or Chlamydia by 50%, and the overall incidence of PID in OC users is reduced by 50%.

  

•   

OCs reduce the risk of ectopic pregnancy by more than 90% in women currently using them.

  

•   

There are three types of injectable contraception: depomedroxyprogesterone acetate (DMPA), norethindrone enanthate, and several progestin–estrogen combinations. All are very effective.

  

•   

Women using injectable DMPA (150 mg every 3 months) intramuscularly or 104 mg subcutaneously have a first-year pregnancy rate of 0.1%.

  

•   

Injectable DMPA is associated with loss of bone density that recovers after DMPA is stopped.

  

•   

Women treated with injectable progestins for contraception have complete disruption of the normal menstrual cycle and an irregular bleeding pattern that is usually followed by amenorrhea.

  

•   

The most effective method of emergency contraception is ingestion of two tablets of 750 ?g of levonorgestrel taken 12 hours apart with a failure rate about 1%.

  

•   

The contraceptive patch is applied to the skin for seven days. Effectiveness and adverse effects are similar to OCs.

  

•   

The contraceptive vaginal ring is placed in the vagina for 3 weeks. Effectiveness and adverse effects are similar to OCs.

  

•   

The cumulative incidence of accidental pregnancy with the copper T 380A IUD is 1.6% after 7 years of use and 1.7% after 12 years of use. This IUD is approved for 10 years' use.

  

•   

The incidence of adverse events with IUDs steadily decreases with increasing age of the woman.

  

•   

The main mechanism of contraceptive action of the copper IUD is production of a local sterile inflammatory reaction of leukocytes, which destroys sperm and prevents fertilization.

  

•   

Resumption of fertility after IUD removal is not delayed and occurs at the same rate as resumption after discontinuation of use of mechanical contraceptive methods.

  

•   

A copper or progesterone-releasing IUD can be removed and a new one reinserted immediately afterward. The IUD can be safely inserted on any day of the cycle.

  

•   

In the first year of use, the copper T 380 IUD has approximately a 0.5% pregnancy rate, a 10% expulsion rate, and a 15% rate of removal for medical reasons, and the incidence of each of these events diminishes steadily in subsequent years.

  

•   

In women wearing a copper T IUD, 50 to 60 mL of blood is lost per cycle; with the levonorgestrel-releasing IUS, the amount of blood loss is about 5 mL per cycle.

  

•   

Mefenamic acid, 500 mg twice daily during menses, significantly reduces menstrual blood loss in IUD users.

  

•   

The fundal perforation rate with the copper T 380 IUD is about 1 per 3000 insertions.

  

•   

The incidence of congenital anomalies is not increased in infants born with any type of IUD in utero.

  

•   

If a woman conceives with an IUD in place and the IUD is not removed, the incidence of spontaneous abortion is about 55%, approximately three times greater than would occur without an IUD. If, after conception, the IUD is removed, the incidence of spontaneous abortion is reduced to about 20%.

  

•   

If a woman conceives with a copper IUD in place, her chances of having an ectopic pregnancy is about 5%, approximately 10 times greater than occurs in conceptions without an IUD.

  

•   

Women using a copper T 380 IUD have approximately a 90% lower overall risk of having an ectopic pregnancy than women using no method of contraception.

  

•   

The rate of prematurity among live births occurring with an IUD in utero is increased about two to four times.

  

•   

The overall risk of PID in users of IUDs with a monofilament tail string is increased only during the first 3 weeks after insertion.

  

•   

Pregnancy rates after reanastomosis of the vas range from 45% to 60%, whereas those after oviduct reanastomosis range from 50% to 80%.

  

•   

About 1% of sterilized women request reversal. In the United States approximately 7000 women request reversal each year.

  

•   

Usually about 15 to 20 ejaculations are required after vasectomy before a man is sterile.

  

•   

After vasectomy, two aspermic ejaculates are required before the male is considered sterile.

  

•   

After sterilization by tubal interruption, the 1-year failure rate is 0.55 per 100 women, the 5-year failure rate is 1.31 per 100 women, and the 10-year failure rate is 1.85 per 100 women. About one third of the pregnancies are ectopic.

  

•   

Complication rates are three to four times higher for second-trimester abortions than for first-trimester abortions.

  

•   

The most effective medical means to terminate pregnancies less than 8 weeks' gestation is the combination of mifepristone followed by misoprostol, with a failure rate less than 5%.

  

•   

A single subdermally placed implant containing etonogestrel provides excellent contraceptive effectiveness for 3 years.

  

•   

A microinsert placed into the oviducts transcervically provides very effective permanent pregnancy prevention.






^ 5.2 Theoretical questions to the class:

  1. What dоes the notion «infertile marriage» comprise?

  2. What are the kinds of infertile marriage?

  3. Qualitative and quantative indices of fertile sperm.

  4. Causes of female infertility.

  5. Diagnostic methods of tubular infertility.

  6. Diagnostic methods of endoscopic infertility.

  7. Algorithm of examination of a family couple with immunologic infertility.

  8. Indications and contraindications for surgical treatment of tubular infertility.

  9. Indications for extracorporal fertilization.

  10. Therapeutic principles of endocrine infertility.

^ 5.3. Practical tasks performed during the class:

1. Methods of functional diagnostics, their estimation.

2. Estimation of the curve of a basal temperature, cytological smears, estimation of the hormone level in the blood.

3. Microscopic picture of the endometrium in various phases of the menstrual cycle.

4. Methods of examination of gynecological patients.

B. Tests for self-assessment

1. Frequency of infertile marriages constitutes:

A. 5-10%

B. 15-20%

C. 5-20%

D. 35-40%

E. more 40%.

2. Can colpitis be a cause of infertility?

A. Yes.

B. No.

3. Can the change of cervical pH be the only cause of infertility?

A. No.

B. Yes.


References:

1. Obstetrics – edited by Professor I.B. Ventskivska, Kyiv “Medicine”, 2008.

2. Gynecology – Stephan Khmil - Ternopil, 2003.

3. Danforth's Obstetrics and gynaecology. - Seventh edition.- 1994. - P. 201-225.

4. Basic Gynecology and Obstetrics. - Norman F. Gant, F. Gary Cunningham. -1993. -- P. 406-412.

5. Obstetrics and gynecology. - Pamela S.Miles, William F.Rayburn, J.Christopher Carey. - Springer-Verlag New York, 1994. - P. 62-64.

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