Insert the FemCap with the long brim side first and the dome

side up. Push until the cap is in contact with the cervix. More spermicide should be

applied if intercourse is repeated. The FemCap should be inserted at least 15 minutes

before sexual arousal and can be left in for up to 48 hours. The FemCap must be left

in place for a minimum of 6 hours after intercourse.

Both devices should be washed with mild soap and water, rinsed and dried, and

stored in the accompanying container. Oil-based products also may decompose the

latex of the diaphragm and should not be used. These devices should be replaced

every year or sooner if there are signs of wear or holes.

Vaginal Sponge

The vaginal sponge is another barrier method. It was taken off the market in 1995 and

re-released in 2003. The sponge contains a polyurethane foam and 1 g of nonoxynol9 (spermicide). The sponge is inserted into the vagina and placed against the cervix.

It may be worn up to 24 hours. After intercourse, the sponge should remain in place

for 6 hours. The sponge works in three ways: It acts as a spermicide, is a mechanical

barrier, and absorbs semen. The failure rate reported is 18% for nulliparous women

and 36% for parous women (Table 47-1).

3

Irritation or ulceration of the cervix and

vaginal mucosa may occur. If the sponge is not removed within 24 hours or if

particles remain after removal, toxic shock syndrome could be an issue. Because the

sponge may cause irritation and does not provide protection against STIs, it may not

be best for C.J.

Male Condoms

Male condoms are an effective method of contraception when used properly. The

failure rate with condoms is 2% to 18% (Table 47-1).

3 Many different brands of

condoms are available in the United States. The brands differ in size, shape, color,

material, and the presence or absence of lubricants or spermicide. The chief

noncontraceptive benefit of latex condoms is the prevention of STIs (including

gonorrhea, chlamydia, and HIV), and they can be used for vaginal, anal, or oral sex.

6

Condoms are readily available without a prescription and do not cause systemic side

effects such as the hormonal methods. However, some complain that condoms reduce

sensitivity and spontaneity. The most commonly used and least expensive male

condom is made of latex.

3 Male condoms made of polyurethane and lambskin are

recommended for men or women allergic to latex. Polyurethane condoms are more

expensive and sometimes break more easily than latex condoms, but they also

conduct heat better than latex.

120 Lambskin condoms also conduct heat well but do not

offer the same protection against STIs as latex and polyurethane. Lambskin condoms

are not recommended for those who are concerned about STIs.

120

Because the pre-ejaculatory secretions may contain sperm, the male condom

should be applied before vaginal contact.

3 When using a male condom, the man or his

partner should hold the tip of the condom and unroll it down to the base of the erect

penis.

6,120 Most practitioners recommend lubricated condoms with resevoir ends to

prevent breakage and collect the ejaculate. Oil-based lubricants can degrade male

latex condoms and should be avoided. Oil-based lubricants, however, may be used

with polyurethane or lambskin condoms. Condoms should be used only once by their

expiration date and stored in a cool, dry place, away from prolonged periods of heat

or light.

Latex condoms would be best for C.J. and her partner to prevent the transmission of

STIs.

Female Condoms

The female condom is less effective, with a 21% failure rate (Table 47-1).

3 The

original female condom known as the FC1 is made of polyurethane. Recently, the

second-generation female condom (FC2) has become available replacing the FC1

(see http://www.fc2.us.com/).

121 The FC2 is made of a nitrale sheath or pouch and

polyurethane ring at the closed end of the pouch. Both condoms consist of a smaller,

circular, inner ring (which secures the device around the cervix like a diaphragm)

and a larger ring around the opening of the condom.

The inner ring should be compressed and inserted vaginally as far as it will go,

and the larger ring remains outside of the vagina, protecting the external genitalia.

Female condoms should also be inserted before sexual contact; they may be inserted

up to 8 hours before intercourse. The FC2 contains a silicone-based lubricant inside

of the condom but additional lubricant may be used. Oil-based or water-based

lubricants can be used with both female condoms. Just like male condoms, they

should be used by their expiration date, not reused, and stored in a cool, dry place,

away from heat or light.

Disadvantages of female condoms include cost (about $3 each), squeaking noise

during use, and insertion difficulty.

3 Condoms may also break, although this is less

likely with the female condom. Male and female condoms should not be used together

as this may increase the risk of breakage.

An advantage for C.J. to use the female condom is that she has control of her own

protection and does not need to rely on her partner to make sure they are both

protected. The female condom is a good alternative for C.J.

Vaginal Spermicides

CASE 47-4, QUESTION 2: C.J. would like to use a spermicide along with condoms. What options does she

have and how effective are spermicides when used alone? What dosage form should C.J. use? How should she

be instructed to use a vaginalspermicide? What side effects can be anticipated?

Vaginal spermicides currently are available as gels (jellies), suppositories, foams,

and films.

3,120 Most of these products use a nonionic surfactant, nonoxynol-9, as the

spermicide. First-year failure rates with these dosage forms range from 18% to 29%

(Table 47-1).

Table 47-6 compares the different spermicidal products.

3,120 The different

characteristics of the products can help guide C.J. when selecting a dosage form.

Regardless of the dosage form, a new dose of spermicide should be applied before

each act of intercourse.

Spermicides may cause genital irritation and in some patients lead to ulceration.

Likely for this reason, spermicides have been shown to increase the transmission of

STIs, including HIV, gonorrhea, and chlamydia. Spermicides may not be the best

choice for C.J. and her partner to prevent the risk of STI transmission.

p. 950

p. 951

Table 47-6

Comparison of Vaginal Spermicides

120

Formulation Brand Name Examples How to Use

Onset of

Action

Duration of

Action

Gel Conceptrol, Gynol II Fill applicator, insert applicator

vaginally as far as it will

comfortably go, press plunger of

applicator to deposit spermicide

near the cervix.

Immediate 1 hour

Film VCF Fold film in half, fold over finger,

use finger to insert as far as it

will comfortably go.

15 minutes 3 hours

Foam VCF Shake foam canister, fill

applicator, insert applicator

vaginally as far as it will

comfortably go, press plunger of

applicator to deposit spermicide

near the cervix.

Immediate 1 hour

Suppository Encare Unwrap, use finger to insert as

far as it will comfortably go.

15 minutes 1 hour

EMERGENCY CONTRACEPTION

CASE 47-4, QUESTION 3: C.J. presents to a pharmacy 4 months later and says she missed her MPA

injection last month. She had intercourse 4 nights ago with a condom and is worried she might become

pregnant. She wants to know whether she should use the “morning-after pill.” What do you tell C.J. about

emergency contraception options? Is C.J. a candidate for emergency contraception?

Emergency contraception (EC), also referred to as the morning-after pill, is

postcoital contraception useful for women who did not use a contraceptive (e.g.,

forgot, were assaulted) or whose method failed (e.g., broken condom, missed pill).

Emergency contraception is available in a few methods, which include oral pills or

an IUD.

Emergency Contraception Pills

Emergency contraceptive pills (ECPs) are available in a variety of formulations

known as progestin-only, Yuzpe, and selective progesterone receptor modulators.

Currently, the one dose progestin-only (levonorgestrel 1.5 mg) ECPs are available

over-the-counter to all ages.

122 The one tablet should be taken within 72 hours of

unprotected intercourse according the package labeling. Studies, however, have

shown that progestin-only ECPs are still effective if taken up to 120 hours (5 days)

after unprotected sex.

108,123 Progestin-only ECPs reduce the risk of pregnancy by a

few potential mechanisms: preventing ovulation, preventing fertilization, or

preventing implantation.

3 They reduce the average risk of pregnancy by 89% after a

single act of intercourse when taken within 72 hours. ECPs are most effective when

taken as soon as possible after intercourse; therefore, treatment should not be

delayed. Progestin-only ECPs may not be as effective in women with a BMI of 26 or

greater and should be recommended to use an alternative ECP but treatment should

not be denied due to BMI.

122 The most common side effects with ECPs are nausea

and vomiting.

3 C.J. should be instructed that if she vomits within 1 hour of taking

ECPs, the dose should be repeated. C.J.’s menses may come early or late, but she

should take a pregnancy test if her menses does not come within 3 weeks of taking

ECPs. This may further be complicated if C.J. gets her next scheduled dose of

injectable MPA.

As an alternative to progestin-only ECPs, regular COCs may be used as long as

they contain levonorgestrel or norgestrel as the progestin. This is known as the Yuzpe

method, which consists of high-dose progestin and high-dose estrogen. There are no

marketed formulations of this method. Depending on the brand of COCs used, a

differing number of pills are taken within 120 hours of unprotected intercourse as

two separate doses 12 hours apart (see Table 47-1 footnote).

3 Compared with

progestin-only ECPs, the Yuzpe method is associated with higher incidence of nausea

and vomiting, and patients may wish to take an antiemetic before each dose.

108

Because progestin-only ECPs are widely available, easy to use, and more effective

and have limited side effects, COCs are being used less often for EC.

A newer ECP classified as an oral selective progesterone receptor modulator

(SPRM), ulipristal acetate (ella), was approved for use in the United States.

124 The

30-mg oral tablet should be taken within 120 hours of unprotected intercourse.

125

It is

available by prescription only. Its mechanism of action is somewhat different from

that of progestin-only ECPs. It has progesterone receptor antagonist and agonist

effects; however, its main mechanism is through receptor antagonism at the uterus,

cervix, hypothalamus, and ovaries, thus preventing ovulation even after the LH surge,

which progestin-only ECPs may not do.

125 The only other SPRM on the market is

mifepristone (RU-486), known for medical abortion use. Concerns were raised about

the mechanism of ulipristal disrupting an existing pregnancy and leading to abortion.

Current pregnancy exposure data do not suggest an increase in miscarriage. Ulipristal

has not been shown to be as effective in women with a BMI of greater than 30 and

may be ineffective in women with a BMI of 35 or greater but treatment should not be

denied due to BMI.

122,124

It is recommended that those women use an alternative

emergency contraceptive method.

122,124 Headache, dysmenorrhea, nausea, and

abdominal pain were the most reported side effects in clinical trials.

124,125

If vomiting

occurs within 3 hours of taking the dose, a repeat dose is recommended.

124

In C.J.’s case, progestin-only ECPs are the better choice because she is taking

medications that interact with COCs. She is within the window of 120 hours

postcoitus making over-the-counter progestin-only ECPs an option. Ulipristal is

another option and labeled for use 120 hours postcoitus, but would require a

prescription and may delay C.J. from receiving timely emergency contraception.

Intrauterine Devices for Emergency Contraception

The copper-T IUD is also an effective method of emergency contraception when

inserted within 5 days of unprotected sex.

3,108 There is no evidence that the progestin

IUD is effective. An IUD

p. 951

p. 952

must be inserted by a healthcare provider and as such may not be used regularly for

emergency contraception. The biggest advantage of using an IUD for emergency

contraception is that it provides continued contraception for the patient. In addition, it

is effective in women regardless of their BMI. Because C.J. is HIV-positive, an IUD

may not be the best choice for her due to infection risk. Also, having to see a

provider for an IUD is less convenient and makes ECPs the better choice for

accessibility and timing.

MEDICAL ABORTION

CASE 47-4, QUESTION 4: C.J. presents to the clinic 4 weeks later stating that she missed her period and is

concerned she may be pregnant. Her human chorionic gonadotropin test is positive, confirming pregnancy. C.J.

considers terminating the pregnancy, stating she is not ready to have a child and is concerned about the

antiretroviral medication effects on the baby. What options are there for medical abortion?

It is estimated that about one-half of pregnancies are unintended, so it is important

for these women to have safe options.

2 C.J. should be counseled extensively about

her options, including keeping the baby, adoption, and medical or surgical abortion.

Compared with surgical abortion, medical abortion does not require a surgical

procedure, so it is less likely to cause infection and is less costly.

3 Thus, some

women feel more in control when choosing this option. However, some patients may

not prefer medical abortion because it usually requires more medical visits and

follow-up, has a slightly lower success rate (94%–97%; failures will need a surgical

procedure), and involves more bleeding and cramping that usually lasts for 2 weeks.

There are many variations in how medical abortions are carried out, but the

general treatment remains the same.

3 C.J. would first obtain baseline laboratory tests,

including blood type and hemoglobin. She would be given either methotrexate,

mifepristone, or both the same day to stop development of the pregnancy. In the

United States, mifepristone, a progesterone receptor blocker, is more commonly

used. Misoprostol is given to induce uterine contractions and expel the pregnancy.

Typically for a gestational age of 63 days or less, C.J. would be given

mifepristone 200 mg orally on day 1, then misoprostol 800 mcg vaginally on day 2 or

3 (6–72 hours after the mifepristone dose).

3 Misoprostol may also be given as 400 or

600 mcg orally or buccally with higher doses of mifepristone (600 mg orally).

3,126–128

If using methotrexate, 50 mg/m2

is given IM on day 1 followed by misoprostol 800

mcg vaginally 3 to 7 days later.

3 Side effects may include nausea, vomiting, diarrhea,

cramping, and vaginal bleeding (heavier than a menses). With either method, patients

should follow up with their healthcare provider on about day 15 to make sure the

abortion is complete. If complete miscarriage has not occurred, another method may

be used, such as aspiration, to remove all pregnancy tissues.

KEY REFERENCES AND WEBSITES

A full list of references for this chapter can be found at

http://thepoint.lww.com/AT11e. Below are the key references and websites for this

chapter, with the corresponding reference number in this chapter found in parentheses

after the reference.

Key References

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contraception in women with coexisting medical conditions. Obstet Gynecol. 2006;107:1453–1472. (26)

ACOG Committee on Practice Bulletins-Gynecology. ACOG practice bulletin No. 110: Noncontraceptive uses of

hormonal contraceptives. Obstet Gynecol. 2010;115:206–218. (83)

American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 152: Emergency

contraception. Obstet Gynecol. 2015;126(3):e1–11. (108)

Dickey RP. Managing Contraceptive Pill Patients. 15th ed. Dallas, TX: Essential Medical Information Systems;

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Hatcher RA et al. Contraceptive Technology. 20th ed. New York, NY: Ardent Media Inc; 2011. (3)

Zieman M, Hatcher RA. Managing Contraception. Tiger, GA: Bridging the Gap Communications; 2012. (5)

Key Websites

Association of Reproductive Health Professionals. http://www.arhp.org/.

Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR

Recomm Rep. 2016;65(No. RR-3):1–104. https://www.cdc.gov/mmwr/volumes/65/rr/rr6503a1.htm?

s_cid=rr6503a1_w (7)

Guttmacher Institute. http://www.guttmacher.org. (111)

International Consortium for Emergency Contraception. http://www.cecinfo.org/.

Planned Parenthood Federation of America. http://www.plannedparenthood.org/. (109)

The Emergency Contraception Website. http://ec.princeton.edu. (122)

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p. 952

Infertility is the inability to conceive after 12 months of unprotected

intercourse. A major predictor of infertility is the age of the woman.

Additional risk factors for both men and women include lifestyle factors,

such as tobacco use and obesity, as well as primary and secondary

causes of hypogonadism.

Case 48-1 (Questions 1–3,

6), Case 48-2 (Questions 1,

2)

The evaluation of infertility in women incorporates data from physical

examination and laboratory assessments of pituitary and ovarian

function. In men, the semen analysis and laboratory assessments of

hormone levels provide key information related to gonadal function.

Case 48-1 (Questions 3–6),

Case 48-2 (Questions 1, 2),

Figure 48-1

Table 48-2

Unexplained infertility is diagnosed after a thorough evaluation of both

the man and woman reveals no identifiable cause. Treatment is empiric

and often combines superovulation with intrauterine insemination or in

vitro fertilization.

Case 48-1 (Questions 7–10)

Clomiphene citrate is a selective estrogen receptor modulator that is

considered a first-line agent for superovulation in patients with

unexplained fertility. Aromatase inhibitors are under investigation as

alternative oral agents.

Case 48-1 (Questions 8–10)

In vitro fertilization is the most commonly used assisted reproductive

technology, or procedure that involves manipulation of oocytes and

sperm. Medications are used to stimulate multiple follicles for oocyte

retrieval and to optimize implantation after embryo transfer.

Case 48-2 (Questions 3–9),

Table 48-4

Controlled ovarian stimulation with gonadotropins is accomplished with

follicle-stimulating hormone alone or in combination with luteinizing

hormone. A gonadotropin-releasing hormone agonist or antagonist is

administered to prevent interruption of the cycle by endogenous

hormones. Human chorionic gonadotropin is injected in a single dose to

finalize follicular development for oocyte retrieval.

Case 48-2 (Questions 4–7),

Tables 48-3, 48-5, 48-6, 48-7

Figure 48-3

A rare but serious complication of controlled ovarian stimulation is

ovarian hyperstimulation syndrome. The risk is minimized by monitoring

the development of follicles carefully with sequential transvaginal

ultrasounds and serum estradiol levels.

Case 48-2 (Questions 5, 7)

Multiple gestation pregnancies are associated with maternal and neonatal Case 48-2 (Question 9)

risks, including preterm birth and extended neonatal intensive care.

These risks are considered when determining embryo transfer and

cryopreservation plans.

The diagnosis and treatment of infertility affects the couple emotionally,

financially, and socially. Psychosocialsupport is an important aspect of

care from the early phases of evaluation and diagnosis through all

stages of treatment.

Case 48-2 (Question 10),

Table 48-8

p. 953

p. 954