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CMDT 2008
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uterine fundus Intracytoplasmic sperm injection (ICSI) allows fertilization with a single sperm It was originally intended for couples with male factor infertility, but it is now used in approximately half of all IVF procedures in the United States GIFT involves the placement of sperm and eggs in the uterine tube by laparoscopy or minilaparotomy With ZIFT, fertilization occurs in vitro, and the early development of the embryo occurs in the uterine tube after transfer by laparoscopy or minilaparotomy The latter two procedures are used infrequently
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The prognosis for conception and normal pregnancy is good if minor (even multiple) disorders can be identified and treated; it is poor if the causes of infertility are severe, untreatable, or of prolonged duration (over 3 years) It is important to remember that in the absence of identifiable causes of infertility, 60% of couples will achieve a pregnancy within 3 years Couples with unexplained infertility who do not achieve pregnancy within 3 years should be offered ovulation induction or assisted reproductive technology Also, offering appropriately timed information about adoption is considered part of a complete infertility regimen
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Refer to reproductive endocrinologist if ART are indicated
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Centers for Disease Control and Prevention, American Society for Reproductive Medicine: 2004 Assisted Reproductive Technology Success Rates 2006, Atlanta, GA http://wwwcdcgov/ART/ ART2004 Sutter P Rational diagnosis and treatment in infertility Best Pract Res Clin Obstet Gynecol 2006 Oct;20(5): 647 64 [PMID: 16769249]
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CONTRACEPTION
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Voluntary control of childbearing benefits women, men, and their children Contraception should be available to all women and men of reproductive ages Education about contraception and access to contraceptive pills or devices are especially important for sexually active teenagers and for women following childbirth or abortion
E Artificial Insemination in Azoospermia
If azoospermia is present, artificial insemination by a donor usually results in pregnancy, assuming female function is normal The use of frozen sperm is currently preferable to fresh sperm because the frozen specimen can be held pending cultures and blood test results for sexually transmitted diseases, including HIV infection
F Assisted Reproductive Technologies (ART)
Couples who have not responded to traditional infertility treatments, including those with tubal disease, severe endometriosis, oligospermia, and immunologic or unexplained infertility, may benefit from IVF, gamete intrafallopian transfer (GIFT), and zygote intrafallopian transfer (ZIFT) These techniques are complex and require a highly organized team of specialists All of the procedures involve ovarian stimulation to produce multiple oocytes, oocyte retrieval by TVS-guided needle aspiration, and handling of the oocytes outside the body With IVF, the eggs are fertilized in vitro and the embryos transferred to the
1 Oral Contraceptives
A Combined Oral Contraceptives
1 Efficacy and methods of use Oral contraceptives have a perfect use failure rate of 03% and a typical use failure rate of 8% Their primary mode of action is suppression of ovulation The pills can be initially started on the first day of the menstrual cycle, the first Sunday after the onset of the cycle or on any day of the cycle If started on any day other than the first day of the cycle, a backup method should be used There are also pills packaged to be taken continuously for 84 days, followed by 7 days of placebos If an active pill is missed at any time, and no
CMDT 2008
progestins gestodene (not available in the United States) or desogestrel compared with women using oral contraceptives with levonorgestrel and norethindrone Women in whom thrombophlebitis develops should stop using this method, as should those at risk for thrombophlebitis because of surgery, fracture, serious injury, or immobilization Women with a known thrombophilia should not use oral contraceptives c Cerebrovascular disease Overall, a small increased risk of hemorrhagic stroke and subarachnoid hemorrhage and a somewhat greater increased risk of thrombotic stroke has been found; smoking, hypertension, and age over 35 years are associated with increased risk Women should stop using contraceptives if such warning symptoms as severe headache, blurred or lost vision, or other transient neurologic disorders develop d Carcinoma A relationship between long-term (3 4 years) oral contraceptive use and occurrence of cervical dysplasia and cancer has been found in various studies A 2002 study showed that there is no increased risk of breast cancer in women aged 35 64 who are current or former users of oral contraceptives Women with a family history of breast cancer or women who started oral contraceptive use at a young age are not at increased risk Combination oral contraceptives reduce the risk of endometrial carcinoma by 40% after 2 years of use and 60% after 4 or more years of use The risk of ovarian cancer is reduced by 30% with pill use for less than 4 years, by 60% with use for 5 11 years, and by 80% after 12 or more years Rarely, oral contraceptives have been associated with the development of benign or malignant hepatic tumors; this may lead to rupture of the liver, hemorrhage, and death The risk increases with higher dosage, longer duration of use, and older age e Hypertension Oral contraceptives may cause hypertension in some women; the risk is increased with longer duration of use and older age Women in whom hypertension develops while using oral contraceptives should use other contraceptive methods However, with regular blood pressure monitoring, nonsmoking women under the age of 40 with well-controlled mild hypertension may use oral contraceptives f Headache Migraine or other vascular headaches may occur or worsen with pill use If severe or frequent headaches develop while using this method, it should be discontinued Women with migraine headaches with an aura should not use oral contraceptives g Lactation Combined oral contraceptives can impair the quantity and quality of breast milk While it is preferable to avoid the use of combination oral contraceptives during lactation, the effects on milk quality are small and are not associated with developmental abnormalities in infants Combination oral contraceptives should be started no earlier than 6 weeks postpartum to allow for establishment of lactation Progestin-only pills, levonorgestrel implants, and depot medroxyprogesterone acetate are alternatives with no adverse effects on milk quality
intercourse occurred in the past 5 days, two pills should be taken immediately and a backup method should be used for 7 days If intercourse occurred in the previous 5 days, emergency contraception should be used immediately, and the pills restarted the following day A backup method should be used for 5 days 2 Benefits of oral contraceptives Noncontraceptive benefits of oral contraceptives include lighter menses, reducing the likelihood of anemia Dysmenorrhea is relieved for most women Functional ovarian cysts are less likely with oral contraceptive use The risk of ovarian and endometrial cancer is decreased The risks of salpingitis and ectopic pregnancy may be diminished Acne is usually improved The frequency of developing myomas is lower in long-term users (> 4 years) There is a beneficial effect on bone mass 3 Selection of an oral contraceptive Any of the combination oral contraceptives containing 35 mcg or less of estrogen are suitable for most women There is some variation in potency of the various progestins in the pills, but there are essentially no clinically significant differences for most women among the progestins in the low-dose pills Women who have acne or hirsutism may benefit from use of one of the pills containing the thirdgeneration progestins, desogestrel, drospirenone, or norgestimate, as they are the least androgenic A combination regimen with 84 active and 7 inert pills that results in only four menses per year is available The low-dose oral contraceptives commonly used in the United States are listed in Table 17 3 4 Drug interactions Several drugs interact with oral contraceptives to decrease their efficacy by causing induction of microsomal enzymes in the liver, by increasing sex hormone-binding globulin, and by other mechanisms Some commonly prescribed drugs in this category are phenytoin, phenobarbital (and other barbiturates), primidone, carbamazepine, and rifampin Women taking these drugs should use another means of contraception for maximum safety 5 Contraindications and adverse effects Oral contraceptives have been associated with many adverse effects; they are contraindicated in some situations and should be used with caution in others (Table 17 4) a Myocardial infarction The risk of heart attack is higher with use of oral contraceptives, particularly with pills containing 50 mcg of estrogen or more Cigarette smoking, obesity, hypertension, diabetes, or hypercholesterolemia increases the risk Young nonsmoking women have minimal increased risk Smokers over age 35 and women with other cardiovascular risk factors should use other methods of birth control b Thromboembolic disease An increased rate of venous thromboembolism is found in oral contraceptive users, especially if the dose of estrogen is 50 mcg or more While the overall risk is very low (15 per 100,000 womanyears), several studies have reported a twofold increased risk in women using oral contraceptives containing the
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