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Birth Control and Infertility

MelissaSchreiber

Risk and ResponsibilityIn the U.S., half of all pregnancies are intendedHalf of unintended pregnancies are terminated by abortionThose who discuss preventing pregnancy are most likely to use contraceptivesOver a period of a year, couples who do not use contraception have a 90% chance of conceptionEvery year, 6.3 million of the 60 million women of childbearing age become pregnant

Pregnancy Outcomes in the U.S.

% Distribution of U.S. Women Age 15-44, By Current Contraceptive Status, 2002

Men, Women, and Birth Control: Who Is Responsible?

Women may have a greater interest than male partners in controlling fertilityHas traditionally been seen as the woman’s job, but society no longer views birth control responsibility as solely women’sMale-controlled methods now account for 35% of reversible contraceptive use

Adolescents and ContraceptionAdolescents are less likely than older individuals to use contraception

55% of women 1st intercourse before age 16 used birth control compared with 70% at age 19 or older

Condoms are preferred method

Condom use may be stigmatized

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Birth Control MethodsRegulate the number of children an individual or couple may haveAlso called contraception (prevent either fertilization or implantation of embryo in the uterine lining)Abstinence – the most reliable method of birth control

Not engaging in sexual behaviorPreventing transmission of STIs

-Refer to page 143 table 9.1

Sexual AbstinenceMost reliable form of birth control

Involves refraining from sexual activity that could cause pregnancy

Abstinence does not necessarily rule out affection or non-coital sexual activities

Practitioners’ definitions of abstinence vary

From a contraceptive perspective, abstinence from vaginal intercourse is required

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Birth Control MethodsMost effective – 90% will not get pregnant

Sterilization and hormonal methods such as birth control pill, injectable medicines, ring, patch, contraceptive implants, and intrauterine devices (IUD)

Second most effective – 85-90% effectiveBarrier methods such as diaphragm, cervical cap, vaginal sponge, and condoms

Third most effective – less than 85% effectiveCoitus interruptus and jellies, creams, and foams

Least effectiveNatural family planning

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Sterilization

Permanent and Irreversible VasectomyTubal Ligation

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Vasectomy

Cutting the vasa deferensSimple operationSmall incisions made on the scrotum to expose the spermatic cordsSmall section of the vasa deferens is removedEach end sealed so sperm are unable to travel to the urethra

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Fig. 09-02

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Tubal Ligation

Uterine tubes are first cut and either tied or sealedPrevents sperm from reaching eggLaparoscopy – two incisions are neededHysteroscopic sterilization – uterine tubes are sealed with an electric current

25% failure rate

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Fig. 09-03

Hormonal Methods

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Birth Control PillUsually a combination of estrogen and progesteroneUsually taken for 21 days out of a 28-day cycleNo pill or inactive pill is taken for the remaining 7 daysExceptions

Lybrel – hormones taken 365 daysSeasonale/Seasonique/Quasense – hormones taken for 12 weeks and inactive pills for 7 daysYaz – hormones taken for 24 days and inactive pills for 4 days

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Fig. 09-01a

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Biological Activity of the Pill

Estrogen and progesterone shut down pituitary production of FSH and LHNo follicle begins to develop in ovaryOvulation does not occurPregnancy cannot occurPill provides female sex hormones for the patient

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Secondary Biological Activities of the Pill

Prevents the cervical mucus from entering midcycle phase of being thin and wateryAffects the transport of an embryo down the uterine tubes so implantation does not occurPrevents normal buildup of the lining of the uterus so an embryo is unable to implantPill accounts for the menstrual cycle to last fewer days and flow is lighter

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Side Effects of the Pill

BeneficialRelief of discomforts with menstruation and relief of acne

AdverseNausea, vomiting, irregular spotting, breast swelling, weight gain, dizziness, blood clots

% of Women Age 15-44 Who Have Ever Used the Pill, 2002

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Alternate Routes of Administration

Depo Provera (only progesterone)Injectable form administered every 12 weeks (~three months)Causes changes in the endometrium that makes pregnancy less likely to occur

Lunelle (both estrogen/progesterone)Once-a-month injection

Vaginal Ring/Nuva Ring (both estrogen/progesterone)

Worn in the vagina for 21 days and removed for 7 days

Hormone Patch – Ortho Evra (both estrogen/progesterone)

Changed every week for three weeks and not worn on the fourth week

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Fig. 09-01f

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Morning After PillAlso known as emergency contraception, Preven, or Plan BMedication that will prevent pregnancy after unprotected intercourse

One, two, or four synthetic progesterone pillsTaken up to 72 hours after unprotected intercourse and 12 hours laterUpsets the normal female reproductive cycle, making it difficult for an embryo to implant itself

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Intrauterine Device (IUD)Small piece of molded plastic that is inserted into the uterus by a physicianCopper type – copper wire wrapped around the stemProgesterone-releasing type – progesterone embedded in the plastic

Mirena – smaller and more flexibleStays in place for 5 years

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Fig. 09-01b

IUD

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Biological Activity and Side Effects of IUD

Biological activityPrevents implantation of the embryo because there is often an inflammatory reaction where the device presses against the endometriumOther theories

Side effectsExpulsion, pain, irregular bleeding, profuse menstruationPelvic Inflammatory Disease (PID)

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Contraceptive Implant

NorplantLong lasting contraceptive implanted under the woman’s skinSix, inch long, silicone rubber tubes containing progestin (synthetic progesterone)

ImplanonOnly used todayOnly one tube, easier to insert and remove than norplant

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Fig. 09-01e

Barrier Methods

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Diaphragm, Cervical Cap, and Vaginal Sponge

Diaphragm – soft rubber or plastic cup with a flexible rim that fits over the cervix

Inserted at most two hours before sexual relationsUsed with spermicide and left in place for at least 6 hours after intercourse

Cervical Cap – thicker and smaller than the diaphragm

Is effective even if left in place for several days

Vaginal SpongeDoes not need to be fitted by a physicianOne size fits all

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Fig. 09-01c

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Fig. 09-04

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Condoms

Male Condom – thin skin or sheath that fits over the erect penis

Ejaculate is trapped inside the sheath and does not enter vagina Protection against STIs

Female Condom – large polyurethane tube with a flexible ring that fits onto the cervix

Also protects against STIs

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Fig. 09-05

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Fig. 09-01d

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Fig. 09-06

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Coitus InterruptusWithdrawalDischarge the semen outside of the vaginaAdvantage

Always available

DisadvantageFirst drop of semen is released before orgasm and contains numerous sperm

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Spermicidal Jellies, Creams, and Foams

Contains sperm killing ingredients such as nonoxynol-9Inserted into the vagina with an applicator up to 30 minutes before intercourseDisadvantage

Women may have an allergy

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Natural Family PlanningRhythm method of birth controlBased on the fact a woman ovulates only once per month and egg and sperm are viable for a limited number of hours or daysSubtract 18 from the shortest cycle

Unsafe period beginsSubtract 11 from longest cycle

Unsafe period ends

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Natural Family Planning Calendar

Shortest cycle: 25 daysLongest cycle: 29 days

Natural Family Planning Calendar

Natural Family PlanningMore reliable method is to await the day of ovulation and wait three more days before engaging in intercourse

Body temperature is lower before ovulationPreceding ovulation temperature drops 0.2°F and following ovulation the temperature rises 0.6°F

Level of sugar in the vagina increases near ovulation (Tes-Tap: yellow turns blue)pH can be tested (acid to alkaline, ovulation is near)Weight of cervical mucous decreases at ovulation 44

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Oral Body Temperature

Abortion

Medical definition: expulsion of the conceptusCan happen naturally (miscarriages)

Can be medically or surgically induced

Abortions are not all the sameCircumstances of pregnancy vary

Differences by stage of pregnancy

Abortion

Conditions matterUnder safe, clean, legal conditions abortion is a safe medical procedure

Self-administered or illegal clandestine abortions can be very dangerous, sometimes fatal

Weeks of Pregnancy When Women Have Abortions

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Abortion

Termination of pregnancy before the fetus is capable of surviving, fetal weight of less than 1 pound

Surgical Abortion – legally available in most statesAbortion Pill – mifepristone (anti-progesterone) and misoprostol (induces contractions)

Methods of AbortionSurgical Abortion

Vacuum AspirationUsed in first trimester and performed under local anesthesia

Most widely used abortion procedure in the U.S.

Dilation and Evacuation (D&E)Used in second trimester

Only 1.5% of U.S. abortions

HysterotomyUsed in later stages of pregnancy

Like a cesarean section, extremely rare

Vacuum Aspiration

Methods of AbortionAbortion Pill

A two-drug regimen (mifepristone with misoprostol) that can terminate early pregnancyMifepristone prevents the cells of the uterine lining from getting the progesterone they need to support the fertilized ovumMisoprostol causes uterine contractionsMost effective when used during the 1st 9 weeks (63 days) after the beginning of the pregnant woman’s last period

Mifepristone and Misoprostol

Prevalence of Abortion

A common experience among U.S. womenApproximately half of unintended pregnancies end in abortionHighest rates among

Ages 18-29, unmarried, Black or Hispanic, and/or economically disadvantaged women

Number of abortions decreased between 1994 and 2000

Emergency contraception accounts for as much as 43% of decrease

Rate of Abortions in Women Aged 15-44 By Year

The Abortion DebateA pro-life argument

Human life begins at fertilizationSame rights in utero as after birthAbortion is moral equivalent of murder

A pro-choice argumentWomen should be able to choose whether or not they will have childrenAbortion should be available as a back-up birth control methodWomen will get illegal and unsafe abortions if the procedure is made illegal

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Infertility

Failure of a couple to achieve pregnancy after one year of regular, unprotected intercourseAMA estimates that 15% of couples are infertile

Attributed to males (40%), female (40%), or both (20%)

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Causes of InfertilityMales

Low sperm count and/or abnormal spermEnvironmental influences

FemalesExtreme underweightPelvic inflammatory disease (PID)Endometriosis – presence of uterine tissue outside the uterusStress

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Assisted Reproductive Technologies (ART)

Techniques used to increase the chances of pregnancy

Artificial insemination – sperm placed in vagina

Drugs are given to stimulate the ovaries

In vitro fertilization (IVF) – conception occurs in laboratory glassware, embryo is transferred to uterus

Assisted Reproductive Technologies (ART)

Techniques used to increase the chances of pregnancy

Intracytoplasmic sperm injection – single sperm injected into an eggGamete intrafallopian transfer (GIFT) – egg and sperm placed in uterine (fallopian) tubes immediately after they have been brought together in laboratory glasswareSurrogate mothers

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Fig. 09-09