Drugs That Modify Fertility Enhance Fertility Female Prolactine producing adenoma Dopamine agonist y Bromocriptin y Pergolide y Cabergoline

Anovulation GnRH agonist (short acting pulsatile) y Gonadorelin y Leuprolide SERMs clomiphene citrate FSH, LH y Urofollitropin y Follitropin Dopamine Agonist Bromocriptin Pergolide Cabergoline MOA Inhibit prolactin release Adverse Effects Nausea Postural hypotension Contraindication Hypersensitivity to ergots SERMs (Selective Estrogen Receptor Modulators) Tamoxifen Raloxifene Breast cancer Osteoporosis (treatment, prevention) Adverse Effects Adverse Effects Hot flashes Hot flashes Libido DVT Endometrial cancer Estrogen antagonist Breast tissue Partial agonist Endometrium Bone Estrogen partial agonist Bone Antagonist Breast Endometrium Types of Contraceptions Female Natural Abstinence Rhythm methods Breast feeding Mechanical Female condom Diaphragm IUCD Drugs Oral contraceptive COCP, POP Long acting progestins (depot, subdermal, implant) Surgery BTL Contraception Prevention of Production of spermatozoa Delivery of spermatozoa into female genital tract Follicular growth, ovulation Oocyte passage through fallopian tube Fertilization Implantation

Male Poor sperm production Anti-estrogen y Clomiphene y Tamoxifen Androgen (mestrolone) Hypogonadism GnRH agonist (short acting, pulsatile)

Clomiphene Induce ovulation Adverse Effects Ovary size Hot flashes Nausea, vomiting Twin pregnancy Estrogen antagonist Hypothalamus Partial agonist Ovary

Male Natural Abstinence Coitus interruptus Mechanical (Barrier) Male condom Drugs GnRH analog Gossypol Surgery Vasectomy

GnRH Agonist Pulsatile mimic natural secretary pattern (Stimulate FSH, LH release )(stimulate ovulation) Gonadoreline Goserelin Adverse Effects y Nausea y Abdominal discomfort y Headache y Flushing y Local pain y Thromboplebitis Continuous administration, long acting ( Gonadotropin, Sexual hormones) Goserelin Histrelin Leuprolide Nafareline Clinical Uses y Prostate cancer y Endometriosis y Precocious puberty y Male contraception Adverse Effects y Hot flushes y Osteoporosis y Sexual dysfunction FSH, LH HMG FSH, LH (prepared from urine of post-menopausal women) HCG LH-like properties (prepared from urine of pregnant women) Adverse Effects Allergic reaction Ovarian hyperstimulation (abdominal discomfort) Multiple gestation

Combined OCP Taken for 21 days followed by a 7-day break allow withdrawal bleeding (mimic normal mensus) Continuously eg. 3 cycles Drug content Estrogen Progestogen (Progestin) Ethinyl estradiol Levanogestrel Microgynon Norethistrone Mestranol Norgestrel Types of Preparation Monophasic constant dose Biphasic, Triphasic Dose High, Medium, Low Hormones That Control Ovulation (-ve Feedback Mechanisms)

Progestogen Only Pills (POP) Norethindrone (0.35mg) Daily (no off-day) Efficacy 97-98% Suitable for breast feeding women Effects Prevent follicular maturation Inhibit ovulation Changes in cervical mucosa, cervical secretion, endometrium Adverse Effects Irregular bleeding (frequent 25% of users) Long Acting Progestogens IM 3 month injection (depot medroxyprogesterone acetate) Effects Inhibit ovulation Change in endometrium, cervical mucosa, secretion Adverse Effects Prolong amenorrhoea Temporary infertility after discontinuation Progestine Implant (eg. L-norgestrel) Multiple capsules implanted under skin (subdermal implant) Irregular bleeding Last for 3 years (can be removed earlier) Intrauterine System (IUS) Eg. Mirena Plastic IUD no copper Release progestogen to act locally Bleeding Prevent systemic adverse effects of progesterone Effective 99.9% Post Coital Contraceptives Dose Estrogen alone/ combination with progestin (COCP, PC4) or POP Not for regular use Effective 97-99% Effects Motility of Fallopian tube Prevent fertilization, implantation Associated with Nausea, vomiting Headache Dizziness Abdominal, leg cramps

Estrogens & Progestogens Estrogen Strongly suppress FSH (prevent follicle development) Suppress LH release (prevent ovulation) Weakly inhibit implantation Not advisable to be used alone (combine with progesterone)

Progestogen Thicken cervical mucous (sperm cannot pass through) Inhibit endometrial development (prevent implantation) Weakly suppress FSH (prevent follicular development) Weakly suppress LH (prevent ovulation)

Benefit Highly effective (99-100%) (require regular consumption) Regular withdrawal bleeding Improves gynaecological problems y Dysmenorrhoea y Irregular menses y Endometriosis Blood loss during menses Ovarian, endometrial cancer risk Adverse Effects Estrogen Progestogen Thromboembolic risk Headache (IHD, MI, Stroke, DVT, PE) Nausea, vomiting Weight Breast, cervical cancer Acne Hepatoadenoma (benign liver tumour) Minor adverse effects Break-through bleeding Weight Headache, migraine Acne Dry eyes Loss of libido (androgen inhibition) Skin pigmentation Vaginal infection Vaginal secretion Contraindication Hypertension Diabetes Stroke IHD Smoking ( 35 y/o) Thromboembolism Impaired liver function Breast cancer/ estrogen dependent tumour Pregnancy/ suspected pregnancy Undiagnosed vaginal bleeding Breast feeding Severe migraine Drug Interactions Antituberculosis antibiotic (Rifampicin) Antiepileptic (Phenytoin, Phenobarbitone)

Males Hormones Negative Feedback Mechanism

Natural Family Planning

Life-span for sperms 3-4 days (may reach up to 7 days for very fertile couple) Life span for ovum +/- 12 hours

Androgen Effects Inhibits sperm production Sperm count to 3x106/ml (oligospermia) Inhibits FSH, LH productions Adverse Effects Acne Weight Oily skin Libido GnRH Agonist Dose/ Extra-long-acting products Effects Sensitivity of anterior pituitary to GnRH GnRH receptors in pituitary (down regulation) Adverse Effects Headache Nausea Libido Gossypol Cottonseed derivative Effects Destroys elements of seminiferous tubules (Does not alter endocrine function of testis) Adverse Effects Hypokalaemia