REPRODUCTIVE PHYSIOLOGY

DR DANBOYI TIMOTHY
Department Of Human Physiology
Kaduna State University

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MENSTRUATION
 This is the regular, cyclical vaginal bleeding that occur as a result of the
shedding of the endometrium.
 It normally lasts 3-5 days with some variations of 1-7 days.
 The normal blood loss is about 30-80ml, normally bright red because 75% is
arterial in origin and does not clot.
 The 2 superficial layers (stratum functionale) are supplied by long, coiled
spiral arteries and the deep layer (stratum basalis) is supplied by short, straight
basilar arteries.
 The high levels of estrogen and progesterone inhibit LH secretion by negative
feedback leading to regression of the CL

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 The hormonal support for the endometrium is withdrawn as the CL
degenerates.
 The endometrium become thinner.
 This adds to the coiling of the spiral arteries, leading to blockage and breakage
in their walls.
 Foci of necrosis coalesce and together with vasospasm produced by PGs leads
to shedding of the stratum functionale.
 This become confluent as the menstrual flow.
 This is mainly arterial (75%) containing tissue debris, PG, fibrinolysin and
ranges from slight spotting to about 80ml.

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Abnormalities of menstruation
 Anovulatory cycle: means no ovulation. There is no secretory phase and the
proliferative phase continues until a menstrual bleed occurs. The menstruation
is usually irregular and heavy. It is common just after menarche and just before
menopause due to insufficient levels of pituitary gonadotropins.
 Dysmenorrhea: refers to painful menstruation due to release of PGs.
 Amenorrhea: means absence of menstruation. It can be primary (when
menarche had never been attained up to 17 years) or secondary (when the
menstruation ceases for some time). Pregnancy is the most common cause of
secondary amenorrhea in a young lady within reproductive age.
 Oligomenorrhea: means scanty menstrual flow. It is usually due to infections
and in polycystic ovarian syndrome.

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 Menorrhagia: means heavy menstrual flow. It could be due to side effects of
some drugs, fibroid, IUCD, cancer, etc.
 Metrorrhagia: means multiple menstrual flow in between normal menstrual
period.
 Cryptomenorrhea: means hidden menstruation. It may be due to an imperforate
hymen, cervical stenosis. It leads to collection of the menstrual blood called
hematocolpos.
 Premenstrual Syndrome: Cyclical, somatic, psychological & emotional
symptoms which worsens as menses approaches & are ameliorated at the onset
of menstrual flow.

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MENOPAUSE
 Menopause is a period when gametogenic & endocrine functions of gonads are
reduced.
 Age: 45-55years.
 Cause: ‘Burning out’ of ovaries due to degeneration of hundred of thousands of ova
during reproductive life.
 Every female fetus has over 7 million ova in utero, many of which become atretic,
leaving about 2million before birth, 50% of which also become atretic at birth.
 The remaining 1 million multiply and grow into the primary oocyte, and undergo
first meiotic division which is arrested at prophase I.
 Atresia continues during growth and development as the no. of ova further decreases
to about 300,000 at puberty.
 Only one reaches maturity per ovarian cycle (500 in the entire reproductive life); the
rest become atretic.
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Physiologic basis of menopause
 At age of 45yrs only few primordial follicles remain to be stimulated by FSH
& LH. There is ovarian insensitivity to stimulation by LH and FSH.
 Estradiol increases slightly until follicular exhaustion when it decreases &
become unable to inhibit production of FSH & LH, hence these hormones are
increased.
 When remaining primordial follicles become atretic, production of estrogen by
the ovaries fall to zero.
 Inhibin B decreases (due to decreasing primordial follicular number)
 At final menses FSH levels 10-15 times higher and estradiol level is 50% less
than that during reproductive years.

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 All these causes a marked hormonal instability, but the testosterone level is
well preserved.
 The ovaries become primarily androgen-secreting organs and oophorectomy
can result in up to 50% decrease in testosterone level.
 The main estrogen is estrone, secreted mainly from the adipose tissue.
 Endometrium builds up but follicles cannot fully mature
Anovulation
No corpus luteum
No progesterone & no stable uterine
lining
Irregular menstruation
Premature Menopause
 Defined as menopause < 40 years of age
 Affects about 1% of women
 Due to:
 Genetic factors e.g. in mosaicism
 Physical conditions factors e.g. ovarian insensitivity syndrome, poor nutrition,
polycystic ovarian syndrome, chronic infection, low body weight, etc.
 Surgically e.g. following oophorectomy or hysterectomy
 Idiopathic e.g. chemotherapy, radiotherapy
Perimenopause/ Cimacteric
 The period prior to beginning menopause
 Length ranges: ~4 years average
 Many begin to experience symptoms
 Many in their 40’s
 Some never notice symptoms
Symptoms Begin During Perimenopause
 Irregular
Mood changes
periods
Depression
Heavy
 or light
 Anxiety
Shorter or longer
amenorrhoea
Palpitations
 

 Hot
Dry flashes
skin and/or hair loss

 Night
Loss orsweats
 sexual desire

 Coldness
Incontinence

 Irritability
Dyspareunia due to vaginal dryness

 Difficulty
Osteoporosis sleeping
later
 Getting to sleep
 Staying asleep
Management
 Watchful waiting
 Symptomatic management depending on presentation
 Management of complications
 Hormone replacement therapy

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FEMALE SEXUAL ACT
 Sexual excitement induces vascular dilatation and engorgement of the vulva,
especially the bulb of the vestibule and clitoris due to parasympathetic activity.
 Dilatation of the submucosal vaginal veins due to release of VIP leads to
transudation of lubricating fluid/mucus from the vestibular glands.
 The sexual excitement is gotten from the upper part of the vagina, which is highly
sensitive to stretch by the erect penis; tactile stimulation of the labia minora, clitoris
and breasts as well as visual, auditory and olfactory stimuli.
 All these stimuli leads to a climax or crescendo characterized by autonomically-
mediated rhythmic contractions of the bulbocavernosus and ischiocavernosus
muscles.
 These together with the highly pleasurable vaginal wall contraction are known as
the female orgasm.
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FEMALE SEX HORMONES
ESTROGENS
 C18 steroid hormones
 Secreted from the ovaries (theca interna and granulosa cells of the ovarian follicles
and luteal cells of the corpus luteum), placenta and the adrenal cortex
 Synthesized from cholesterol. There are 3 types
 Estradiol (most potent),
 Estrone, and
 Estriol
 Estradiol and estrone are also formed by aromatization of testosterone and
androstenedione by aromatase enzyme.
 Metabolised in the liver to glucuronide and sulfate conjugates and excreted in urine.

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Functions of estrogens
 Increase in size of female sex organs (ovaries, fallopian tubes, uterus & vagina)
during puberty.
 Breasts: development of stromal tissues, ductile system & deposition of fat.
 Stimulate bone growth by inhibiting osteoclastic activity.
 Increase in body metabolism & fat deposition.
 Skin: soft & smooth.
 Electrolytes: cause sodium & water retention by the kidney tubules.

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PROGESTERONE
 C steroid hormone
19
 Secreted from the ovaries and the placenta.
 Functions include:
 Promotes secretory changes in the uterine endometrium during latter half of
monthly ovarian cycle.
 Promotes increased secretion by the mucosal lining of fallopian tubes necessary for
nutrition of fertilized ovum.
 Breasts: development of the lobules & alveoli.

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RELAXIN
 Relaxin is a polypeptide hormone that is produced in the corpus luteum, uterus,
placenta, and mammary glands in women and in the prostate gland in men.
 During pregnancy, it relaxes the pubic symphysis and other pelvic joints and
softens and dilates the uterine cervix. Thus, it facilitates delivery.
 In men, it is found in semen, where it may help maintain sperm motility and
aid in sperm penetration of the ovum.

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PHYSIOLOGY OF PREGNANCY
 For pregnancy to occur, intercourse must take place at most 5 days to ovulation
or on the day of ovulation.
 The fusion forms a zygote, an actively dividing cell which moves to the already
prepared endometrium for implantation at about 6 days post-fertilization.
 Within this period, the zygote under a number of mitotic cell division called
cleavage, without any change in size, up to a 32-cell morula.
 Each cell in the morula is totipotent i.e. capable of developing into an entire
individual.
 The morula develops into the blastocyst (having a cavity filled with fluid within
the inner cell mass) then becomes surrounded by layers of trophoblastic cells
which burrow deep into the endometrium till the embryo is well-implanted at
the fundus of the uterus.
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 The embryo develops into the foetus while the trophoblastic cells develops into
the placenta, which takes over the nourishment of the foetus and maintains the
pregnancy.
 The placenta also secretes some hormones such as estrogen, progesterone,
relaxin, hCS, etc.
 The average duration of gestation or pregnancy is 280 days or 40 weeks from
the last menstrual period.

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Maternal Changes During Pregnancy
Psychological changes
 Mood changes between happiness and sadness
 She may become aggressive and irritable, at one time and happy and friendly
at other times.
 There can be emotional inhibition depending on the circumstances of the
pregnancy e.g. rape, forced marriage, etc. or excited if she is pregnant for the
first time after so many years of trying to.
GIT changes
 There is an initial suppression of appetite but later becomes voracious. Craving
for abnormal foods may occur. She may dislike her favourite food and develop
other favourites.
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 Increase salivation, spitting, nausea and vomiting may occur.
 There could be constipation too.

Respiratory changes
 There is increase in tidal volume and respiratory rate as the pregnancy
advances.
CVS changes
 Increase in heart rate, cardiac output with normal or decrease in peripheral
resistance and blood pressure.
 Pregnancy-induced hypertension (toxaemia of pregnancy) may occur. It is
associated with proteinuria, oedema and sometimes convulsion (ecclampsia).
 There is left axis deviation in ECG.

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Blood and body fluid changes
 The plasma volume increases by about 50% and the total blood volume by 30%
 There is about 30% increase in RBC mass but the PCV decreases, a condition
called dilutional anaemia. This is due to the non-commensurate increase
between the RBC mass and plasma volume.
 Leucocyte and platelet counts as well as plasma protein levels remain
unchanged.
Renal changes
 Increase urinary frequency and mild hydronephrosis occur

Reproductive changes
 The uterus increases in size (hypertrophy and hyperplasia occur).
 Formation of mucus plug that closes the cervical canal. This prevents PID and
secure amniotic fluid.

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Endocrine changes
 Corpus luteum in the ovary enlarges at the time of fertilization in response to
stimulation by placental gonadotropin called human chorionic gonadotropin
(hCG).
 The enlarged corpus luteum of pregnancy secretes estrogens, progesterone &
relaxin.
 Relaxin causes softening and relaxation of the ligaments around the pelvic
girdle especially the pubis symphysis. It also maintains pregnancy by inhibiting
myometrial contractions.
 From the 6th week of gestation, the placenta produces sufficient estrogen &
progesterone from maternal & fetal precursors that take over the function of the
corpus luteum.
 The function of the corpus luteum begins to decline after 8 th week of pregnancy
but persists throughout pregnancy.
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 Estrogen & progesterone increase until just before parturition while hCG
decreases after an initial marked increase.
 Thyroid gland secretion and size increases. These increase the BMR and
prepares the mammary gland for lactation.
 Decrease insulin secretion from the pancreatic beta-cell. This causes
gestational diabetes in some women.
Breast changes
 Marked increase in size of the breast due to oestrogen (which causes ductal
proliferation) and progesterone (which causes alveolar proliferation).
 Human chorionic mammotropin (hCM) from the placenta and prolactin also
contribute to these changes.
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Abnormalities of Pregnancy
 Prolonged pregnancy
 Bleeding (APH)
 Infection (PID, chorioamnionitis, TORCHES sundrome)
 Hypertension
 Other systemic diseases (jaundice, malaria, renal, heart, DM, SCD etc.)
 Coexisting myoma
 Fetal abnormalities (IUGR, IUFD, etc.)
 Abortion
 Malpresentation
 Multiple pregnancy*

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PHYSIOLOGY OF PARTURITION
 Parturition means birth or delivery of a baby. It is the sum total of all the
process involved in the act of giving birth. It is also called labour.
 The uterus becomes progressively excited toward the end of pregnancy until it
develops a rhythmical contractions that cause expulsion of the baby.
Stages of labour
 Labour occurs in stages:

1. Stage 1: it is the period between the onset of strong regular uterine

contraction to the dilation of cervix and opening of vaginal canal.
2. Stage 2: refers to the period from full cervical dilatation to the delivery of the
baby.
3. Stage 3: the placenta is detached from the decidua and expelled out.

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Initiation of Labor
 Theoretical  Artificial
 Maternal factors  Cervical exam
Progesterone  Stripping of membranes
Estrogen
 Prostaglandins
Oxytocin
 Artificial rupture of membranes
Prostaglandin
 Sex
Psyche
 Nipple Stimulation
 Fetal factors
Fetal cortisol
First Stage – Latent Phase
 Few days leading up to active labour
 Prostaglandin mediated ‘ripening’ of cervix occurs
 Irregular contractions begin effacement
 ‘Bloody show’ – mucous and blood which previously plugged cervix
liquefies. Likely also mediated by prostaglandins.
 Membranes can rupture at any time (often assisted but ARM is NOT
part of normal labour). This event tends to trigger active labour, again
likely due to the release of prostaglandins (true mechanism not fully
understood)
First Stage – Active Phase
 Said to begin once regular contractions established, or effaced cervix 3cm
dilated (in a multigravida)
 Cervix dilates at approximately 1cm/hour and is incorporated into lower
segment
 Upper segment progressively shortens and thickens, due to spirals of smooth
muscle contractions.
 Lower segment stretches and thins
 Ends when cervix is 10cm dilated (‘Fully’)
Second Stage
 Begins when cervix fully dilated
 Lasts about 1hr in primipara, 30 mins in multipara but lenthened by
epidural analgesia
 Upper segment continues to shorten and thicken. Majority of fetus in
lower segment
 Head passes intraspinous diameter – the narrowest part of the pelvis
 Perineum softened by congestion with blood (not unlike arousal)
 Delivery accomplished by the following six manoeuvres:
Six manoeuvres of delivery
1. Engagement of the fetal head in the transverse position. The baby is looking
across the pelvis at one or other of the mother's hips.
2. Descent and flexion of the fetal head
3. Internal rotation. The fetal head rotates 90 degrees to the occipito-anterior
position so that the baby's face is towards the mother's rectum.
4. Delivery by extension. The fetal head passes out of the birth canal. Its head
is tilted backwards so that its forehead leads the way through the vagina.
5. Restitution. The fetal head turns through 45 degrees to restore its normal
relationship with the shoulders, which are still at an angle.
6. External rotation. The shoulders repeat the corkscrew movements of the
head, which can be seen in the final movements of the fetal head.
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Third Stage
 From delivery of fetus to delivery of placenta
 Usually within 15-30 mins (depends on choice of active or expectant
management)
 Immediately after delivery, contractions tend to stop for brief period
 Placenta separated due to ‘shearing effect’ of uterus contracting after foetus
delivered, thereby reducing size of site of attachment.
 Retroplacental haematoma forms, exuding downwards pressure
 Active management is now so common to be considered NORMAL
 Oxytotic (commonly syntocinon) given by IM injection to stimulate
uterine contraction
 Placenta can be delivered by maternal effort or by controlled cord traction
(CCT)
 Active Management has been shown to reduce PPH
Mechanism of labour
 Several hormones play various roles to bring about a successful parturition.
 Progesterone maintains pregnancy by decreasing the sensitivity of the
myometrium to oxytocin. Its secretion however, markedly decreases near full
term, to allow initiation of labour.
 Relaxin loosens the ligament of the pubis symphysis make wider exit for the
head of the baby during labour. It increases the number of oxytocin receptors
on the myometrium and simultaneously suppress the inhibitory action of
progesterone on uterine contraction. It also facilitates development of the
mammary gland.
 Estrogen increases the number of oxytocin receptors on the myometrium.

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 Oxytocin causes contraction of the fundal smooth muscle which enhances
labour and stimulates the release of PGs in the decidua. Myometrial oxytocin
receptors increases both in number and sensitivity.
 Prostaglandins (PGs) facilitates labour by increasing the force of contraction
 Fetal hormones: fetal pituitary secretes oxytocin, adrenal gland secretes
cortisol & fetal membranes release prostaglandins. These 3 increase uterine
contractions.
 Mechanical Factors: Stretch of uterine musculature and stretch of the cervix
also reinforces uterine contractions. There is a reflex contraction of the
abdominal muscles initiated from the uterus or vagina. They can also contract
voluntarily.

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Abnormalities of Parturition
 Prolonged labour
 Obstructed labour
 Uterine inertia/atony
 Malpresentation/malposition
 Cord/hand prolapse
 Bleeding
 Perineal tear

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PHYSIOLOGY OF LACTATION
 This is the process of milk synthesis and ejection from the mammary gland.
Breast milk synthesis has two components: lactogenesis (initiation of milk
synthesis) and galactopoeisis (maintenance of the synthesis).
 Large quantities of estrogen from the placenta cause ductal system to grow &
branch. Also, the stroma increases in quantity & fat are deposited in them.
Progesterone causes full development of the lobule-alveolar system of the
breasts.
 Estrogen & progesterone inhibit the actual secretion of milk.

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Lactogenesis
 There is evidence of milk synthesis from the 4th month of pregnancy due to the
action of prolactin. This lactogenic effect is inhibited by the high level of
estrogen and progesterone in the blood. Immediately after parturition, there is
sudden crash in the estrogen and progesterone levels, which removes this
inhibition.
 Prolactin promotes lactation by enhancing milk secretion. It rises steadily from
the 5th week of pregnancy until birth at which time it has risen 10-20 times the
normal nonpregnant level.

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Galactopoeisis
 This has both endocrine and mechanical components. Insulin, thyroid
hormones, growth hormone and prolactin are required to maintain continuous
milk synthesis and ejection. Oxytocin helps in the milk ‘let down’ reflex, the
mechanical component (initiated by suckling of the baby).
 Suckling of the nipple stimulates touch receptors which send impulses to the
supraoptic and paraventricular nuclei of the hypothalamus to secrete oxytocin
from the posterior pituitary gland. The oxytocin stimulates the contraction of
the myoepithelial cells surrounding the ducts, thereby squeezing the milk out.
 Emotional stimuli & genital stimulation in lactating women produce oxytocin
& sometimes cause milk ejection from the breasts

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Abnormalities of lactation
 Lactation failure: no synthesis of breast milk due to either hormonal or receptor failure.
 Galactocele: cystic distension of the alveoli or ducts, which may be due to a distal
obstruction of a duct.
 Galactorrhoea: refers to excessive flow of milk particularly when the lady has not had a
recent pregnancy or delivery.
 Chiarri-Frommel syndrome: consists of hyperprolactinemia, amenorrhoea and
infertility. It is often due to pituitary tumours (gonadotromas)
 Mastitis: painful swelling of the entire breast mostly due to blockage leading to an
inflammatory change. It can also be due to an infective process.
 Breast engorgement: this is due to either much more milk is synthesized than is suckled
by the baby or there is a distal blockage.
 Sore nipples: cracks or ulceration around the nipple with associated pains.

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PREGNANCY TESTS
 The physiological basis for pregnancy test is to detect the presence of beta-
hCG in the blood or urine. It can be detected in the mother’s blood 6 days after
conception or in the urine 14 days after. The tests include:
 Immunological tests: involves interaction between hCG antigen and antibodies
in the blood or urine. It may results false negative if the test is performed at
early stage of pregnancy or false positive for women using drugs containing
hCG molecule or nonpregnant production of hCG.
 Chemical test: assesses the concentration of the hCG.
 Biological test: the presence or absence of hCG is assessed by administering
the urine to certain animal say for example, rabbit and note if ovulation occurs
48 hours later.

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 Obstetric ultrasonography: is the use of medical ultrasonography in which
sound waves are used to create real-time visual images of the developing
embryo in the uterus. The embryo can be observed and measured by about 5
weeks of gestation.
 Early pregnancy factor (EPF): can detect pregnancy within 2 days after
fertilization. EPF is tested for rosette inhibition assay. Using an antiserum to
peripheral blood lymphocytes. EPF is present in the maternal serum, cervical
mucus and amniotic fluid.

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ROLE OF PG
 Prostaglandins are produced from placenta, uterus & almost all tissues in the
body.
 Induce parturition by enhancing uterine contraction.
 Aid transport of sperm by increasing receptive capacity of cervical mucosa.
 Degeneration of corpus luteum

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PHYSIOLOGY OF CONTRACEPTION
 This refers to the prevention of pregnancy in both males and females. Some
methods used include:
 Oral contraceptive pills (OCP): they usually contain oestrogen with or without
progesterone. There is also progestin-only contraceptives. They act by negative
feedback inhibition of GnRH and gonadotropin secretion by the hypothalamus
and pituitary gland respectively. The progesterone thickens the cervical mucus
and makes sperm migration impossible.
 Injectible contraceptive: also contain estrogen and progesterone, they act by
negative feedback inhibition of ovulation.

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 Intra-uterine contraceptive devices (IUCDs): these are self-retaining devices,
inserted into the uterine cavity to prevent both fertilization and implantation (if
fertilization occurs). They can cause menorrhagia, infection and get displaced
 Barrier methods: these prevents fertilization and are of different types e.g.
condoms, cervical sponge, cervical caps, cervical diaphragms, etc.
 Spermicidal creams: they are applied on the vagina just before coitus to kill
sperm cells release during coitus.
 Surgical methods: in the females, both tubes can be ligated to prevent
fertilization. In the males, vasectomy (bilateral ligation or cut of the vas
deferens) or sterilization can be done.

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 Natural methods: this include coitus interuptus (prevents intra-vaginal
ejaculation), billing (ovulation) method (having coitus only during the ‘safe’
periods of the menstrual cycle), lactational amenorrhoea method, cycle beads
method, etc. The unsafe period is between 4 days before ovulation and 3 days
after.
 Emergency contraception (post-coital):

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Combined Oral Contraceptive (COC)
 Is a widely available method of contraception.
 Is a combined pill composed of synthetic oestrogen and progestogens.
 Brands of COC pills: Oestrogen are: Ethinylestradiol(20, 30, 35 & 50mcg) or
Mestranol (50mcg). While progestogens are: Norethisterone acetate (0.5,1.0 &
1.5mg) and Levonorgestrel (150 & 250mcg). 3rd gen. : Gestodene, Desogestrel and
Norgestimate.
 The COC is a convenient, reversible and highly effective contraceptive with a perfect
use failure rate of 0.1% in the 1st year.
 Mode of action is a combination of inhibition of ovulation (90-95% of time) through
the suppression of the pituitary release of follicle stimulating hormone (FSH) and
luteinising hormone(LH), alteration of the cervical mucus and endometrial atrophy.
Advantages
 COC pills has many non-contraceptive effects that are beneficial:
(a) Menstrual: Regular menstrual cycles, Lighter menstrual loss, painless
menstruation, eliminates mid-cycle ovulation pain, delay timing of menstruation
and frequency, improvement of pre-menstrual syndrome.
(b) Sexual benefit
(c) Others: Reduced risk of PID, anaemia, ectopic pregnancy, Rx for acne, hirsutism &
Androgenic symptoms e.g. PCOS
(d) Reduced risk of malignancy *
Contraindications

ABSOLUTE RELATIVE
 Suspected pregnancy  Irregular vaginal bleeding
 Suspected malignancy  Obesity
 Focal migraine  Heavy smoking
 Acute heart or severe liver disease  Diabetes mellitus
 Severe hypertension  Long term immobilisation
 CVA  Age over 35 (with other factors)
 Acquired or inherited prothrombotic tendency  Sickle cell dx
 Risk factor for Cardiovascular dx
 Thrombo-embolism
Complications
(a) Venous thromboembolism
(b) Myocardial infarction and stroke
(c) Neoplasia
(d) Other S.Es:
CNS:- depression, headache and loss of libido.
GUS:- irregular bleeding, vaginal discharge, cystitis and enlargement of fibroids.
Alimentary system:- nausea, vomiting, cholestatic jaundice and weight gain.
Leg cramps and facial pigmentation.
Progestogen only pills(POP)
 This method is suitable for for clients who exhibit oestrogen intolerance or have oestrogen related risk
factors such as cardiovascular dx.
 A pill is taken everyday with no break. POP has a failure rate of 1-3 per 100 woman years.
 Mechanisms of action:
-prevention of ovulation in half cycles
-Thickening of cervical mucus rendering the mucus impervious to sperms.
-Endometrial changes that decrease receptivity to implantation.

Advantages include: Decrease in menstrual loss, decrease in dysmenorrhea and ovulation pain, possible
protection against endometrial cancer, possible reduction of PID risk, Rapid return to fertility.

Disadvantages: Menstrual:- unpredictable irregular bleeding but reduced overall blood loss; Amenorrhoea
Psychosexual
Injectable contraceptives
Two main groups:
i) Progesterone only injectables namely depot medroxy progesterone acetate(DMPA) 150mg and
norethisterone oenanthate.
ii) Combined oestrogen-progestogen injectable. Main prep here is Lunelle containing a suspension of
25mg medroxy progesterone acetate and 5mg oestradiol cypionate.
 The contraceptive effectiveness of injectable is 0.1-2 failures per 100 woman-years.
 Mechanism of action of progestogen injectables is similar to that of the POP, while that of Lunelle is
similar to combined oral contraceptives.
Advantages
 Safe and highly effective
 Can be used by lactating mothers
 Prevents haemorrhagic corpus luteum
cysts.
 Suppresses ovulation pain
 Convenience, not coitally related
 Diminished fear of pregnancy
Disadvantages
 Unpredictable spotting and bleeding in
the first 1-3 months.
 Mood swings, depression and anxiety
may develop.
 Weight gain.
 Delay in return of fertility(DMPA)
 Mastalgia in some women
 No protection against STI
Subdermal progestogen contraceptive
 Contraceptive implants are increasingly being used for fertility regulation.
 They have practical advantage of overcoming the risk of user failure and low
continuation rates associated with other methods that require continous motivation.
 Have 2 main groups: Biodegradable & Non-biodegradable.
 One group, Norplant I & II, containing levonorgestrel, the other group Implanon
contains Etonogestrel.
Mechanism of action:
 Thickening of cervical mucus consistently through the cycle to prevent sperm
penetration.
 Ovulation suppresion
Advantages
 Decreases dysmenorrhoea and ovulation
pain.
 Decreases menstrual blood loss.
 Requires little user compliance or
motivation.
 Secondary amenorrhoea with a reduced
incidence of IDA
 Can be used by women who have
contraindications to oestrogen.
 Decreased risk of PID…..
Disadvantages
 Irregular bleeding and spotting during the
1st 12months
 Spotting and bleeding may interfere with
sexual and cultural activities
 Persistent ovarian follicle syndrome
 Insertion and removal require trained
personnel
 Offers no protection against STI
 Risk of ectopic pregnancy with Norplant
 Potential allergy
Post-coital Contraception
 Sometimes referred to as “morning after” or emergency contraception.
 Provides a 2nd chance for women who experience contraceptive failure or do not use a
method, as well as for women who experience unplanned intercourse, including coerced sex
or rape.
 Two primary methods of emergency contraception:
(1) Use of a higher dose of oral contraceptive pill
(2) Insertion of an intrauterine device.
 Hormonal post-coital contraceptives can also be used: The combined method- Schering PC4-
two tablets each containing 50mcg ethinylestradiol and 250mcg levonorgestrel(or 500mcg of
norgestron) repeated after 12hrs. 1st dose must be taken within 72hrs of unprotected
intercourse. The progesterone only method
Post-coital (contd)
 Consists of two doses of levonorgestrel 750mcg, which are also taken 12 hours apart, the first
within 72 hrs of unprotected intercourse.
 Copper IUCD can help prevent unwanted pregnancy if used up to 5 days of unprotected
intercourse.
 The Mirena intrauterine system has a slower action compared with the effect of copper
devices on sperm and blastocysts and is not recommended.
 In all cases of emergency contraception, if the client has not had a menstrual period within 3
weeks of treatment, a pregnancy must be excluded.
Intrauterine Contraceptive devices
 The modern IUDs have either copper or levonorgestrel on their frame and are of varying
shapes and sizes.
 Mode of action:-
 Locally induced inflammatory reaction in the endometrium
 Toxic effect of copper on sperms: inhibiting sperm motility and activation of acrosome
reaction (Copper IUD)
 Local endometrial suppression and thickening of the cervical mucus making it impervious to
sperms.
 Contraindications include: Congenital malformation of the uterus, Genital tract malignancy,
Suspicion of pregnancy, Immunosuppresive states, Unexplained uterine bleeding, previous
history of PID, previous hx of ectopic pregnancy, allergy to copper and Wilson’s dx.
Advantages
 Convenient method of contraception with
very low failure rate.
 Method not related to intercourse,
permitting spontaneity of sexual activity.
 Rapid return of fertility on removal.
 Cost effective
 Ideal method for women who cannot
remember to use pills everyday.
 Improves menorrhagia and may decrease
hysterectomy rates.
Disadvantages
 Increases in menstrual loss (Copper IUD
only)
 Slight risk of pelvic infection in first 20
days post insertion (1 in 100 women)
 May increase dysmenorrhoea
 Spotting and uterine cramps in the first 3
months post insertion.
 Insertion may be painful resulting in vaso-
vagal attack.
 Risk of infection, perforation and
expulsion.
Barrier methods of Contraception
 Male method: Condoms
 Female condoms: disposable polyurethane sac with an outer ring at the level of the
introitus and loose inner vaginal ring.
 Diaphragm and cervical cap and sponge: are female barrier methods, usually used
with spermicides to improve efficacy.
 Spemicides
Sterilisations
 Both male and female are permanent methods of contraception hence it is imperative
that clients requesting these methods should be adequately counselled and written
consent obtained.
 Female sterilisation: Tubal sterilisation is achieved surgically or chemically. The
method of choice is laparoscopic approach.
 Male sterilisation: vasectomy is a permanent male contraception that involves
division and ligation or cautery of the vas deferens.
PATHOPHYSIOLOGY OF INFERTILITY
 Infertility is defined as a diminished capacity to conceive and bear a child,
while sterility, the absolute and irreversible inability to conceive.
 Clinically, a couple is considered infertile if they are unable to conceive after
12 months of unprotected, frequent coitus.
 In 30% of cases the problem is in the man; in 45%, the problem is in the
woman; in 20%, both partners have a problem; and in 5% no cause can be
found.
 It is assumed to be caused by either abnormal physiological function of the
genital system or abnormal genetic development of the ova.
 Most common cause is failure of ovulation due to hyposecretion of
gonadotropins

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 Specific disorders causing infertility include those involving each of the major
physiologic events necessary to produce a pregnancy:
1. Production of a healthy egg;
2. Production of healthy sperm;
3. Transportation of the sperm to the site of fertilization;
4. Transportation of the zygote to the uterus for implantation;
5. Successful implantation in a receptive endometrium
6. Presence of other conditions, some immunologic, that can interfere with one
or more of the other events.

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Oocyte abnormalities
 The main cause of female infertility due to oocyte abnormalities is a failure to ovulate
regularly or, in some cases, at all.
 Resulting in oligo-ovulation or anovulation are also causes of amenorrhea, and fall into three
categories:
 hypothalamic dysfunction,
 pituitary disease and
 ovarian dysfunction
 Common hypothalamic causes of anovulation include abnormalities of weight and body
composition, strenuous exercise, stress and travel.
 Pituitary or endocrine disorders associated with anovulation are hyperprolactinemia and
hypothyroidism.
 The two most common known causes of ovarian dysfunction are polycystic ovary syndrome
and premature ovarian failure

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Female anatomic abnormalities
 Endometriosis: a condition in which endometrial tissue grows & even
menstruates in the pelvic cavity surrounding the uterus, fallopian tubes &
ovaries.
 This condition occlude fallopian tube or prevent release of ovum.
 Fallopian tubal disease: usually the result of inflammatory scarring of the
fallopian tubes.
 This may be caused by pelvic inflammatory disease, appendicitis with rupture,
septic abortion, salpingitis (inflammation of the fallopian tubes). It causes
fibrosis thereby, occluding the tubes.
 Abnormal mucus (viscous mucus plug) from the uterine cervix that prevents
fertilization

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 In men, most common causes of infertility are:
 Cryptorchidism
 Low sperm count: below about 20 million/mL.
 Abnormal morphology of the sperm.
 Nonmotile sperm.
 Hyposecretion of testosterone or gonadotropins

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Treatment
 Medical
 Surgery
 If surgery unsuccessful, IVF, GIFT and ZIFT are best options

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Intrauterine insemination (artificial
insemination)
 definition: sperm introduced into female reproductive
tract by means other than coitus
 sperm can come from donor / sperm bank or from
husband
IUI, cont’d.
 usually, several ejaculations are pooled
 6000 babies / year born in US. as result of artificial insemination
 often used when male has low sperm count or antibodies present in ejaculate
In vitro fertilization
 “test - tube babies”
 1st performed in 1978 (Louise Joy Brown)
 often performed on infertile women with tubal
blockage
IVF Protocol
 GnRH agonist (e.g. Lupron) for 7 days
 FSH agonist (follistim, Gonal-F, Repronex) until
follicles measure 17-20 mm in diameter
 hCG given to induce egg maturation
 Egg retrieval (transvaginally) 34-35 h later
IVF protocol
 sperm and ova added to dish; fertilization occurs 12-
14hrs.
 eggs transferred to new dish and cell division occurs
 embryos squirted into uterus at 4- to 32-cell stage
(optimal: blastocyst stage)
IVF Protocol, cont’d.
 3 to 5 embryos are injected to increase chances of
pregnancy
 woman given progestagen to prevent miscarriage
IVF Protocol, cont’d.
 new variations / improvements:
 Intracytoplasmic sperm injection (ICSI)
 use of frozen embryos
 27,000 attempts made per year; 18.6% successful
(success rates are increasing)
 http://www.advancedfertility.com/sampleivfcalend
ar.htm
IVF, cont’d.
 Ethical questions:
 will it lead to selective breeding?
 up to what stage can research be done?
 if embryo dies in vitro, is it abortion, murder?
 what should be done w/ unwanted embryos?
 should government regulate research?
GIFT and ZIFT
 GIFT = gamete intrafallopian transfer
 useful for tubal blockage
 ova are collected and inserted into oviducts below
point of blockage
 husband’s sperm are placed in oviduct
GIFT and ZIFT
 woman is treated with hormones to prevent
miscarriage
 4200 attempts made / year; 28% successful
 ZIFT = zygote intrafallopian transfer
 ZIFT is like IVF, only zygotes (1 cell stage) are
inserted below blockage in oviduct (24% success
rate)
Others
 Ovarian stimulation protocol
 Surrogate pregnancy
 Adoption