Contraception and Sterilization Flashcards
(111 cards)
1
Q
Almost what percent of pregnancies in US are unintended
A
almost half (45%)
2
Q
what percent of unwanted pregnancies - women not desiring pregnancy but not using birth control
A
40%
3
Q
Why use contraception? (5)
A
- No desire to have children
- Space out having children
- Limit family size
- Avoid effects of pre-existing illness on pregnancy
- May also be used as treatment for disorders, including:
- Endometriosis
- Polycystic Ovarian Syndrome (PCOS)
- Premenstrual Dysphoric Disorder (PMDD)
4
Q
Contraceptive non-use more likely if patient is:
A
- Lower income
- Uninsured
- Never married
- Zero or one parity
5
Q
Top reasons for non-use contraceptive included:
A
- Not minding if they got pregnant (22.6%)
- Worried about contraceptive side effects (21.0%)
- Not thinking they could get pregnant (17.6%)
6
Q
T/F: laws for contraception in Adolescents vary by state and situation - in many cases, parental consent for contraception not needed
A
T
- 27 states and DC - allow all minors to consent to contraceptive services
- 19 states - allow minors to consent if certain specified conditions are met
- 4 states - no explicit policy on minors’ ability to consent to contraceptive services
General consensus - adolescents should be given contraceptive and sexual health education and prescriptions
7
Q
- Withdrawal of penis before ejaculation
- Requires sufficient self-control by male partner
- Likely high failure rate but no reliable statistics
- Escape of semen before orgasm possible
- Deposition of semen on external female genitalia
A
Coitus Interruptus
8
Q
what is Postcoital Douche
A
- Plain water, vinegar, or commercial product
- Theory - will flush semen out of vagina
- Additives may have spermicidal properties - Sperm have been found in cervical mucus < 90 sec after ejaculation
- Ineffective and unreliable
9
Q
what is Lactational Amenorrhea
A
Suckling → reduced GnRH, LH and FSH
Must maintain amenorrhea!
10
Q
If breastfeeding is exclusive - menses for first ? months after birth are usually anovulatory
A
6 months
- 0.9-1.2% pregnancy rate
- After 12 months - 7.4% pregnancy rate
- Not as effective if supplemental feeding
11
Q
Recommendation to use reliable contraception
starting ___ months after delivery if no pregnancy desired
A
3
12
Q
Basis - avoiding coitus during the time when an ovum and motile sperm could meet in the oviduct
A
Periodic Abstinence
13
Q
fertile period of Periodic Abstinence
A
2-3 days before ovulation to 2-3 days thereafter
14
Q
5 Methods of Periodic Abstinence
A
- Calendar Method
- Temperature Method
- Combined Temperature/Calendar Method
- Cervical Mucus (Billings) Method
- Symptothermal Method
15
Q
what is the Most effective determinant in periodic abstinence
A
serum LH peak
- Not cost-effective or time-effective
- Can be useful in treating infertility
16
Q
Possible increased incidence of ____ resulting from unplanned pregnancies while using periodic abstinence
A
congenital anomalies among children
- May be due to delayed fertilization
- No conclusive proof
17
Q
Predicts ovulation after recording menstrual pattern for several months
Requires regular menstrual cycles
MC method of periodic abstinence
Least reliable method - 35% failure rate in 1 yr
A
Calendar Method
18
Q
Ovulation normally ? days before 1st day of
next menstrual period
A
14
19
Q
- More efficacious than calendar method
- Records basal body temperature (BBT) - Preferred vaginal or rectal temperature
- Taken in AM, before any physical activity
- Timing of ovulation for any given cycle is retrospective
A
Temperature Method
20
Q
temp method: Slight drop in temperature when?
A
- 24-36 hrs after ovulation
- Temperature then rises 0.3-0.4 C (0.5-0.7 F) and stays there for the rest of the cycle
21
Q
temp method: what day indicates end of fertile period
A
Third day after onset of elevated temperature
22
Q
- Dates of menstrual cycles are calculated and temperature is recorded daily
- Among well-motivated and compliant couples - failure rates of only 5 pregnancies per 100 couples per year
- Less perfect use - higher pregnancy rates
which method?
A
Combined Temp/Calendar
23
Q
- AKA “Billings Method”
- Predicts ovulation by observing changes in cervical mucus
- Simplicity and no need for charting
- Difficulty of evaluating mucus if vaginal infection present
- Women may not wish to evaluate secretions
which method?
A
Cervical Mucus Method
24
Q
Several days before to just after ovulation - cervical mucus becomes ?
rest of menstrual cycle - mucus becomes ?
A
- thin and watery
- thick and opaque
25
* Combines cervical mucus and temperature methods
* Also uses symptoms that may occur just before ovulation
* Likely **most effective** of all periodic abstinence methods
Symptothermal Method
26
sx that may occur just before ovulation (9)
1. Bloating
1. Breast tenderness
1. Increased vaginal moisture
1. Increased sex drive
1. Spotting
1. Mittelschmerz
1. Nausea
1. Headache
1. Vulvar swelling
27
Contain an estrogen and a progestin
Often used interchangeably with OCPs
which type of OC?
COCs - Combination Oral Contraceptives
28
types of estrogen for COC?
which is MC?
**ethanyl estradiol (MC)**, mestranol, 17β-estradiol, or estradiol valerate
29
types of progestin for COC?
which is also a spironolactone analogue?
* norethindrone, levonorgestrel, desogestrel, norgestimate, drosperinone
* Drospirenone
30
which progestins are less androgenic
higher VTE risk
progestins
* 3rd gen - **desogestrel, norgestimate**
* 4th gen - **drospirenone**
31
Newer COC formulations use less hormones for less side effects, name the 2
1. **Monophasic** - same dose of hormones daily
1. **Multiphasic** - different doses of hormones during cycle
32
* COC - 21 days of active hormone followed by ___
* Newer preparations now?
* 7 days of placebo
* Newer preparations - 24 active pills, 4 inert pills
33
with COC what can you expect after stopping active pills?
withdrawal bleed 2-5 days after stopping active pills
34
how to start COC? (ideal, traditional, quickstart?)
1. **Ideal** - begin COC the first day of a menstrual cycle
1. **Traditional** - begin the Sunday following the onset of menses
1. **Quickstart** - begin any day of the cycle (commonly the day prescribed)
- may improve short term compliance
Strongly encourage **regular routine of taking pills same time daily**
35
Steps after missing a pill of COC?
1. Single-missed dose, high-dose monophasic - conception is unlikely
- Make up pill next day will minimize breakthrough bleed
2. Multiple missed doses or missed dose of lower-dose pills
- Double next dose, add barrier contraceptive technique for next 7 days
3. **Any** missed pill + coitus in past 5 days - consider emergency contraception
36
MOA of COC
Suppression of Ovulation
* Suppression of FSH and LH → no follicular development
* Alter consistency of cervical mucus
* Make endometrium less receptive to implantation
37
DDI with COC
* **Anticonvulsants** - MC class overall for interactions
* **Antibiotics** - controversial - macrolides, PCNs, rifampin
* **Other** - warfarin, acetaminophen, SSRIs
38
benefits of COC use?
1. **Reduced cancer risk**
- Ovarian cancer (40-80%)
- Endometrial cancer (50%)
2. **MSK benefits**
- Improvement in bone mass
- Decreased progression of rheumatoid arthritis
3. **Others**: Improvement of acne
4. **Other women’s health benefits**
- Lower risk of ectopic pregnancy (90%) and PID (50-80%)
- Decrease in benign fibrocystic breast disease (30-50%)
- Improvement in dysmenorrhea and premenstrual s/s
39
major SE of COC
1. **Venous Thromboembolism (VTE)**
- _Higher risk_ - recent leg trauma, pelvic surgery, factor V Leiden, venous stasis
2. **MI** - only if RF (HTN, DM, dyslipidemia, smoking, age >35)
- Low risk, but high mortality (50%)
3. **Stroke** - hemorrhagic or ischemic
- Relative increase in risk by 2-10x
- _Higher risk_- smoking, increased age, migraines, HTN
4. **Liver Disease**
- May affect liver function or incr risk of cholelithiasis and cholestatic jaundice
- Older, higher-dose - incr risk of liver neoplasia
5. **Cervical Dysplasia/Cancer** - incr risk
6. **Breast Cancer** - controversial
40
3 cautions with COC
1. May cause or worsen HTN or headaches
1. **AVOID** women w/ migraines + aura
1. May impair quality and quantity of breast milk
41
minor SE of COC
1. nausea, dizziness, fatigue
1. weight gain of 2-5 lb
1. abnormal menses (missed period, spotting or breakthrough bleeding)
1. decreased libido
1. melasma
*Often improve after the first few months of use*
42
CI of COC
1. Pregnancy
1. Undiagnosed vaginal bleeding
1. Migraine with aura
1. Prior history of VTE, MI, or stroke
1. Increased risk for CV sequelae: Active SLE, Uncontrolled DM, Uncontrolled HTN
1. Cigarette smokers over age 35 years
1. Current or prior breast cancer
1. Active liver disease
43
T/F: Small daily quantity of progestin alone does not suppress ovulation
T
44
benefits & cons of POP
Benefits
1. No side effects of excess estrogen - safe in women who cannot take estrogen
1. No special sequence of pill-taking
Cons
1. Must take at **same time each day** - even 2-3 hr delay diminishes efficacy for ~48 hrs
1. Higher rates of irregular bleeding
1. Higher overall pregnancy rate
45
MOA of POP
Unknown
Theorized - cervical mucus becomes less permeable
Endometrial activity may go out of phase
46
Ideal candidates for POPs
1. Older women who smoke
1. Sickle cell anemia
1. Migraines
1. HTN
1. SLE
1. Breastfeeding women
47
CI of POP
1. Unexplained uterine bleeding
1. Breast cancer
1. Hepatic neoplasms
1. Pregnancy
1. Active severe liver disease
48
Preventive contraception after unprotected intercourse or failure to use a contraceptive method properly
**Will not** prevent contraception later in cycle
Emergency Contraception
49
3 methods of Emergency Contraception
1. Yuzpe method
1. Levonorgestrel
1. Copper IUD
50
what is the Yuzpe method?
SE?
EC - COCs with levonorgestrel
1. 100 μg ethinyl estradiol and 500–600 μg levonorgestrel
1. 2 doses, 12 hours apart
- **1st dose - within 72 hrs of intercourse**
- The sooner taken after intercourse, the more effective it is
1. Nausea in 50% and vomiting in 20%
- pre-medicate with antiemetic
51
* Single dose of 1500 μg (MC) or two 750 μg doses taken 12 hrs apart
* Recommended ASAP, ideally within **72 hrs** of intercourse - May be effective as long as 5 days after intercourse
* Prevents LH surge - Does not stop fertilization or implantation
which type of emergency contraceptive
Levonorgestrel (Plan B One Step, Aftera))
52
what is ulipristal (Ella)
Emergency contraception
* Single dose of 30 mg
* Recommended within 72 hrs of intercourse - May be effective as long as 5 days after intercourse
* Prevents LH surge; may also help delay ovulation after LH surge - Does not stop fertilization or implantation
53
* May inhibit implantation or possibly interfere with sperm function
* Insert up to **5-7 days** from time of intercourse
which type of emergency contraception
Copper IUD (Paragard)
54
May inhibit implantation or possibly interfere with sperm function
Insert up to **5 days** from time of intercourse
Levonorgestrel IUD 52 mg (Liletta, Mirena)
55
IUDs are generally preferred for emergency contraception due to…
1. Better efficacy rates for pregnancy prevention
1. No drop in efficacy with increased BMI
1. Can be left in place to prevent future pregnancies
56
* **Combo** - ethinyl estradiol and etonogestrel or segesterone
* Worn **3 weeks per month**
* Maintains efficacy even if removed for up to 3 hrs
* Designed to be left in place during intercourse
* No fitting needed
* _Failure_ - 0.65 per 100 woman-yrs
which type of Contraceptive
vaginal ring - “NuvaRing,” “EluRyng,” “Annovera”
57
SE of flexible vaginal ring
SE similar to COCs
* Slightly less breakthrough bleeding and spotting
* Vaginal discomfort, leukorrhea, vaginitis, coital problems
* Disposable - 50 mm diam, 4 mm thick; Reusable - 56 mm diam, 8.4 mm thick
58
1. Approximately 20 square cm
- **Combo** - ethinyl estradiol and either norelgestromin or levonorgestrel daily 7 days
2. **New patch Q wk x 3 wks**, followed by patch-free wk
3. _Failure_ - 0.7 per 100 woman-yrs perfect use
- 0.88 per 100 woman-yrs for typical use
- Possible higher failure rate for overweight/obese women
which type of contraceptive method?
Transdermal Patch - “OrthoEvra”, “Xulane”, “Zafemy”, “Twirla”
59
SE and CI of transdermal patch
Same CI, potential risks and SE as COCs
* Slightly more breast sx and dysmenorrhea
* 60% more estrogen in serum - Possible higher VTE risk
* Potential for local irritation
60
if transdermal patch comes off, what do you do?
attempt to reattach
* Detached < 24 hrs - cycle continues as usual
* Detached > 24 hrs - new patch, backup
* contraception for 1 week
61
2 Non-Oral Short Term Hormonal contraceptives
1. vaginal ring
1. transdermal patch
62
types of Long-Acting Hormonal and IUDs
1. Depot Medroxyprogesterone Acetate
1. Implants - “Implanon,” “Nexplanon”
1. Copper IUD - “ParaGard;" Levonorgestrel IUD - “Mirena”
63
dosing & effects of depot shot?
1. 150 mg of 17-acetoxy-6-methyl **progesterone** IM Q **3 mo**
1. Suppresses FSH/LH, thickening cervical mucus, thinning of endometrium
- Perfect use - 0.3 pregnancies per 100 woman-yrs
- Typical use - 3 pregnancies per 100
woman-yrs
64
benefits and SE of depot shot
**Benefits**:
1. Lower risk of ectopic pregnancy
1. Lower risk of endometrial cancer (up to 80%)
1. Lower risk of sickle cell crises
1. May improve endometriosis
1. Does not increase risk of vascular disease
**Major SE** - decreased bone density
1. Can also cause irregular menses
- Prolonged menstrual flow and spotting for first 6 months
- Often amenorrheic later in course of therapy
2. May see headaches, breast tenderness
3. No strong association with weight gain, mood changes, or hair loss
**Up to 10 months to return to baseline fertility**
65
* Rod-shaped implant which releases etonogestrel, a **progesterone**
* Usually inserted in upper arm
* Approved for up to **3 years** - _Studies suggest may work up to 5 years_
what type of contraception?
MOA?
SE?
**implant**
* changes cervical mucus and tubal motility, can interfere with gonadotropin release, alters endometrium
* Very high efficacy - No reported pregnancies
* No major complications; **Minor** - bruising, pain, swelling, itching, fibrosis
* **SE** - irregular menses, wt gain, HA; No major impact on bone density
66
* FDA-approved for 10 years (may be good for longer)
* MOA - thought to be spermicidal, interfere with with ovum development or fertilization, and cause inflammation of endometrium
which type of IUD?
Risks and SE?
copper
1. **Risks and Side Effects** - ectopic pregnancy, spontaneous abortion, uterine perforation, expulsion
- Associated with lower risk of cervical, endometrial, and ovarian cancer
1. **Minor Side Effects** - menstrual irregularities, cramping, vaginitis
67
CI to copper IUD
1. **Intrauterine Contents**
- Pregnancy or suspected pregnancy
- A previously placed IUD that has not been removed
- Distorted uterine cavity
2. **Infections**
- Acute PID
- Postpartum or postabortal endometritis or septic abortion in the past 3 months
- Mucopurulent cervicitis
3. **Uterine / cervical cancer** (known or suspected) - Genital bleeding of unknown etiology
4. **Wilson disease**
5. **Allergy** to any component of ParaGard
68
1. lifespan of up to **8 years**
1. Blood levels of levonorgestrel are 25% of those among users of OCPs
1. **52 mg dose**
1. Thins endometrium, thickens cervical mucus, decreased tubal motility
1. Anovulation in 10-15% of cycles
1. Irregular menses 1st 3-4 months of use
- After - significant decrease in menstrual flow; up to 20-25% amenorrheic
- Dysmenorrhea tends to improve
which type of IUD?
Risks and SE?
Levonorgestrel IUD - “Mirena”
* **Risks and SE** - ectopic pregnancy, spontaneous abortion, uterine perforation, expulsion
* **Minor SE** - irregular menses, headache, acne, mastalgia
69
* Same dose of levonorgestrel as Mirena (**52 mg**)
* Similar device size and tube size for insertion
* Approved duration - up to **8 years**
* May also help treat heavy
* menses or dysmenorrhea
which type of IUD
Levonorgestrel IUD - “Liletta”
70
1. Lower dose of levonorgestrel than Mirena (**19.5 mg**)
1. Smaller device size and smaller tube size for insertion
- May be better suited for women with a smaller uterus
- May have lower expulsion rate
1. Approved duration - **5 years**
1. **Not** approved to treat heavy menses or dysmenorrhea
which type of IUD
Levonorgestrel IUD - “Kyleena”
71
1. Lower dose of levonorgestrel than Mirena (**13.5 mg**)
1. Smaller device size and smaller tube size for insertion
- May be better suited for women with a smaller uterus
- May have lower expulsion rate
1. Approved duration - **3 years**
1. **Not** approved to treat heavy menses or dysmenorrhea
Levonorgestrel IUD - “Skyla”
72
CI to progesterone IUD
1. **Intrauterine Contents**
- Pregnancy or suspected pregnancy
- Distorted uterine cavity
- A previously placed IUD that has not been removed
2. **Infections**
- Pelvic infection or current PID
- Postpartum or postabortal endometritis or septic abortion in the past 3 months
- Untreated acute cervicitis, vaginitis, or other lower genital tract infections
3. **Cancer**
- Uterine or cervical cancer (known or suspected) - Genital bleeding of unknown etiology
- **Breast cancer** (known or suspected)
4. **Acute liver disease** or liver tumor (benign or malignant)
5. **Hypersensitivity** to any component of IUD
6. Prior **ectopic pregnancy**
73
If strings are not able to be felt:
| IUD
1. Use backup contraception
1. Gently probe endocervical canal to look for
1. IUD strings
1. Perform pregnancy test (if indicated)
1. Consider TVUS to determine IUD location
74
types of Barrier and Physical Methods for contraceptives
1. Spermicides
1. Contraceptive Sponge
1. External (Male) Condom
1. Internal (Female) Condom
1. Diaphragm + Spermicide
1. Cervical Cap
75
* Creams, jellies, suppositories, film, foams
* Most are available without a prescription
* Especially useful for temporary protection or secondary to other methods of contraception
* **High pregnancy rates d/t inconsistent use**
* **Do not protect against STDs**
* Can cause **local inflammation**
Spermicides
76
MC active ingredient in spermicides?
effect?
**Nonoxynol-9**
Destroys sperm body and flagella
Approximately $20 per 10 doses
77
what is Phexxi in spermicides and what does it do?
* lactic acid, citric acid, potassium bitartrate
* Lowers vaginal pH, causing sperm to become immobile
* Approximately $270 per 12 doses (pending insurance coverage)
78
how to use spermicides?
Must be placed high in vagina, in contact with cervix, shortly before intercourse
Maximal duration of effectiveness - around **1 hour**
Avoid douching for at least 6 hrs after
79
1. Nonoxynol-9-impregnated polyurethane disc
1. Efficacy unchanged by frequency of coitus
1. More convenient but less effective than diaphragm or condom
what contraceptive method?
how to use it?
Contraceptive Sponge
* Inserted up to 24 hrs prior to intercourse
* Moistened and placed against cervix
* Must remain in place for 6 hrs after coitus
80
* Cover for the penis during coitus
* Prevents deposition of semen in vagina
* **MC used mechanical contraceptive in the world**
* Commonly latex - may be polyurethane or lamb ceca
* Should be recommended for **all couples** except mutually monogamous relationship
what contraceptive method?
which one is **not** impermeable to most organisms?
Pros and cons?
* **External (Male) Condom**
* Lamb’s cecum condom
* Advantages: Highly effective, inexpensive, **Protects against STIs**, May have spermicides for additional protection
* Failure - imperfections of manufacture, errors of technique, and escape of semen from the condom
81
Thin polyurethane with 2 flexible rings
One ring - depth of vagina
One ring - near the introitus
what type of contraceptive method?
pros and cons?
Internal (Female) Condom
* Advantages: Under control of female partner; Some protection against STDs - May reduce risk of HIV by 90%
* Disadvantages: Relatively expensive; Overall bulky
*Failure rate in perfect use - 2.6%*
82
1. Circular rubber dome supported by a metal spring
1. Mechanical barrier between vagina and cervix
what method of contraceptive?
SE?
Diaphragm + Spermicide
SE - vaginal irritation, increased UTIs
Some protection against STIs
83
in Diaphragm + Spermicide where is the spermicide applied?
on **cervical side**
84
Diaphragm + Spermicide
method is ineffective without ?
spermicide
85
how to use diaphragm + spermicide?
* Position so that the cervix, vaginal fornices, and anterior vaginal wall are partitioned from the remainder of the vagina and penis
* Place up to **6 hours** before intercourse
* Leave in place **6-24 hours after**
86
1. Small, cuplike diaphragm placed over cervix
- Held in place by suction
- Must fit tightly over cervix
- May be used with spermicide
1. Similar efficacy to diaphragm
1. Leave in place for 8-48 hrs after intercourse
1. Confirm placement over cervix after each sexual act
which method of contraceptive?
cons?
Cervical Cap
cons: Difficult to fit cap properly; Many women unable to feel their own cervix; May use for 1-2 days, but foul discharge usually develops after 1 day
87
2 types of sterilization
Bilateral tubal ligation and hysteroscopic tubal sterilization
88
for sterilization, what must be done first before proceeding?
Careful **counseling and documentation** must be done first!
1. Advise of risks and benefits
1. Explain procedure
1. Done surgically, often laparoscopically
1. Warn of possibility of **regret**
- _After 5 years_ - 7% of female patients, 6% of male patients expressed regret
- _Probability of regret_ - **20**% for pts ≤**30** y/o, 6% for pts >30 y/o
- _Other risks_ - nonwhite pts, unmarried pts, postpartum sterilization, Medicaid
89
US federal funding prohibits permanent contraception for:
1. Patients < 21 years old - Some individual states provide funding for females 18-21 years old
1. Patients who are mentally incompetent
90
* Patients with federally funded insurance must have a signed consent form ___ days prior to the permanent contraception procedure
* Some states allow waiting period to be reduced to 72 hours
30-180
91
types of Female Tubal Sterilization?
reasons of failure?
1. **Electrocoagulation** - “burning” - destruction of segment
- Low long-term failure rate, but _highest serious complication rate_
2. **Mechanical tubal occlusion**
- Via rubber band or metal clip
- _Favorable long-term success rate_
3. **Ligation of tube with suture material**
- +/- removal of section of fallopian tube
4. **Salpingectomy**
- Complete removal of fallopian tube - newest procedure, estimated high efficacy
**Reasons for failure** - surgical error, tubal fistula, reanastomosis, equipment failure, luteal pregnancy
92
SE of Female Tubal Sterilization
1. **ectopic pregnancy** - esp **electrocoagulation**
1. Post Tubal Ligation Syndrome
1. Menstrual irregularities - Less duration, less volume of flow, less dysmenorrhea
1. **Decr risk of ovarian cancer** - _Greatest reduction in risk with salpingectomy_
1. **2x functional ovarian cysts**
1. No change in sexual interest or pleasure in 80% - Of remaining 20% - 8 out of 10 found positive changes
93
* Mechanical devices or chemicals to block the oviducts
* Done via **cervical canal** and uterine cavity rather than laparoscopically
* **No longer available in US**
Tubal Occlusion
94
what are the 2 Mechanical Tubal Occlusions that are no longer sold in the US
1. **Essure** Permanent Birth Control - 2019
- Stainless steel coil surrounded by polyester fibers and nickel/titanium alloy outer coil
- Fibroblastic proliferation causes occlusion
1. **Adiana** Permanent Contraception - 2012
- 60-second radiofrequency thermal injury to proximal fallopian tube
- Followed by insertion of nonabsorbent silicone elastomer matrix
95
benefits and drawbacks of Mechanical Tubal Occlusion
* **Benefits**: Can be done in office (local anesthesia, IV sedation); Success rates of >95%
* **Drawbacks**: HSG must be done at 3 mo to verify occlusion; incomplete occlusion; allergic reaction; May not work in pts with faulty immune/inflammatory response
96
1. Placement of agents into the uterine cavity or tubal ostia to incite an inflammatory response to the tubal occlusion
1. Quinacrine pellets placed into the uterine fundus
1. Potential for **carcinogenesis and toxigenesis** - **Never received FDA approval for US use**
Chemical Tubal Occlusion
97
what is Male Sterilization
1. Often done in-office with local anesthesia
1. Lumen of the vas deferens is disrupted to block sperm
- **30x less failure and 20x less postop** complication rates vs female sterilization
1. Sterility **not immediate**
- Need 1-2 consecutive sperm counts of zero
1. **Reversal** - surgical reanastomosis or by sperm retrieval from testis
98
Deliberate termination of pregnancy in a manner that ensures the embryo or fetus will not survive
Elective Abortion
99
how to eval pts for pregnancy termination
1. **Evaluate preparedness**: Ascertain patient desires abortion for her own reasons; knows about alt to abortion; Ensure social support
1. **Ascertain if elective or for medical/surgical reason**
1. **Complete social hx, medical hx and PE**: Accurate gestational age; hCG, UA, hematocrit, Rh, syphilis, G/C culture, and Pap
100
1. **Safest and most effective method** for pregnancies
- performed at **< 12 wks** gestation
- >90% of abortions in the US
1. Can do with paracervical block +/- sedation
1. Cervix is dilated and suction cannula inserted into uterine cavity
- light instrumental curettage afterward
which method of termination?
advantages?
**suction curettage**
1. **Advantages** - rapid, minimal blood loss, low risk of perforation
- Very low failure rates and very low mortality rates
101
* Dilation of cervix - use instruments to scrape inside of uterine cavity
* **Higher risk** for uterine injury than suction
* Not common since advent of suction curettage
which method of termination
surgical curettage
102
regimens of Medical (Pharmaceutical) Abortion?
which is MC
1. mifepristone (Mifeprex) + misoprostol (Cytotec) - **MC and highly effective**
1. methotrexate + misoprostol (Cytotec)
1. misoprostol (Cytotec) alone
1. oral anti-progestin (RU-486) followed by misoprostol 48 hours later
103
when is medical abortion used?
pros and cons?
CI?
* 1st-trimester, **< 49 days** from FDLMP
* **Benefits** - cheaper, less invasive, and less scarring risk; no need for anesthesia
* **SE** - cramping, bleeding, and failure to evacuate uterus
* **CI** - active liver or renal disease, severe anemia, acute IBD, bleeding risk (coagulopathy, anticoagulant therapy)
104
what imaging to obtain after medical abortion?
what if abortion has not occured?
US 24 hrs later to determine if passage of gestational sac
* If abortion has not occurred, repeat misoprostol dose and f/u in 4 weeks
* If abortion has not occurred by _2nd_ follow-up, suction curettage
* Follow-up is more frequent if FHT persist
105
what is Intra-Amniotic Instillation
1. For induced abortion after **1st trimester**
1. **Original procedure** - amniocentesis, aspiration of as much fluid as possible, and installation of 200 mL hypertonic (20%) NaCl solution
- Usually - spontaneous labor and expulsion of fetus
within 48 hours of instillation
1. **Now** - hyperosmolar urea, MC with oxytocin or prostaglandin,
or intra-amniotic prostaglandin alone
- May also use cervical ripening agents
**High complication rate** - up to 20%
106
* Vaginal suppositories containing misoprostol, mifepristone-misoprostol, or other prostaglandins
* Trigger preterm labor and delivery
* 20 mg every 3-4 hours until abortion occurs
which method of termination?
risks?
major disadvantage?
Vaginal Prostaglandins
* Risk of incomplete abortion and complications similar to instillation agents
* **Major disadvantages** - significant GI side effects, high incidence of live abortion, maternal fever
107
Use in OB/GYN - induce abortion, cervical ripening, labor induction, treatment of incomplete or missed abortion
synthetic prostaglandin E1
Causes uterine contractions and cervical ripening
Less expensive than dinoprostone (Cervidil)
which method of termination?
SE?
DDI?
1. **Misoprostol (Cytotec)**
1. **SE**: Miscarriage-like sx (cramping, bleeding); N/V/D; HA; dizziness, fatigue
1. chills or hot flushes
1. **DDI**: **oxytocin**; Increased risk of diarrhea if given with **Mg-antacids**
108
1. MC for 2nd-trimester abortions
- Modification of suction curettage
- Can be performed with IV sedation and paracervical block up to 18 wks
1. Cervical ripening agents used
1. Large suction cannulas and specially designed forceps to break up and remove fetal tissue from the uterus
which method of termination?
variants?
complications?
Dilation and Evacuation
1. Variant - “intact D&E” or “D&X”
- Fetus is delivered breech and intact until skull lodged above the cervix
- Skull is decompressed using suction and fetus is fully delivered
1. Complications - hemorrhage, perforation, infection
- < instillation or prostaglandins
- No sensation of undergoing labor
109
2 Other Abortion Methods
1. **Hysterotomy/Hysterectomy** - Reserved for special situations (i.e., cervical stenosis); Much higher morbidity and mortality than other methods
1. **Menstrual Regulation** - Aspiration of endometrium within 14 days of a missed menstrual cycle or 42 days after beginning of last menstrual period; Used more when pregnancy tests were not readily available; Similar complications to suction curettage - higher failure rates
110
post-abortion f/u
1. **RhoGAM** to all Rh- pts
1. Pt should take **temp** several times daily and report fever or unusual bleeding at once
1. **Avoid intra-vaginal products x 2 wks** - Intercourse, tampons, douches, medication
1. **Emotional depression** may occur after induced abortion
1. Provide **effective contraception**
111
Long-term abortion sequelae (1 & 2+ procedures)
* **1 procedure** - essentially unchanged risk vs. pts with one normal pregnancy
* **2+ procedures** - possible increased risk for mid-trimester pregnancy loss
* No correlation with ectopic pregnancy risk
