Infertility and
Contraception
Lecture 14

Infertility: inability to conceive > 1 year of regular sexual
intercourse without contraception or inability to carry
pregnancy to live birth.

Incidence – 15% of couples of child-bearing age in U.S.
2.5 million American couples
Primary infertility- no previous conceptions.
 Secondary infertility- previous birth but unable to

conceive now.
Fertility Testing Procedures
 Semen analysis (inexpensive)
 FSH, LH, estrogen, progesterone levels (blood test)
Ovulation Determination by:
Basal Body Temperature (temp.
slightly just
before, then
~ 98.6 immediately > ovulation)
^ by ~ 1 degree (12-24 hours)
1st thing in morning before anything.
Daily temps. plotted on graph for 3-4 mos.
Urine Test Strip - LH upsurge < ovulation (ovulation
predictor kits)
Cervical Mucous Test (done @ home)
 “Spinnbarkeit “=stretching of cervical mucous @
time of ovulation [d/t ^ estrogen]
How to Check for Ovulation…

Usually occurs on day 14 – 20 of menstrual cycle. Can be
done with a regular cycle. *Count 14 days back from
menses; accurate estimation of ovulation.

Calendar Method: keep diary of ~ 6 months of
menses. To help locate fertile days using
calendar method, you would teach:
Subtract 18 from shortest period and 11 from
longest. (irregular cycle)
Range of days - “possibly” fertile.


Fallopian Tube Obstructions
“Hysterosalpingography” - X-ray Imaging




Radiologic exam of fallopian tubes using
radiopaque dye.
Catheter placed in cervix. Dye passes through
filling uterus & fallopian tubes.
Structures/adhesions in uterus/tubes & tube
patency assessed
Dye “blows out” tubes – clears obstruction;
infertility resolved.
Hysteroscopy – visual inspection of uterus
 hysteroscope: thin, hollow, lighted tube through cervix. Allows
direct inspection of uterus. FU procedure to
hysterosalpinography if abnormalities found.
 CO2/saline used.
 Diagnostic (local) or Operative (IV sedation)
Surgical Evaluation: (general)
Laparoscopy – insertion of thin, hollow, lighted tube thru incision
made below umbilicus. CO2 gas inflates cavity.
 Examines fallopian tubes & ovaries; checks distance between
ovaries & tubes; if distance too great, ovum can’t enter tube.
Remove growths (fibroids, masses, polyps, scar tissue) TL,
ectopic pregnancy, hysterectomy.
 Video camera used
Frequent Initial tests are:
 Semen Analysis
 Basal Body Temp.[graph temp.]
 Sperm Penetration Assay [penetration ability]
 Post-coital Test
 Endometrial Bx. [assess level of estrogen & proges.]
Other Fertility Procedures:
 Meds: Clomid, Serophene (^ ovulation)
 Increasing sperm count (abstinence 7-10 days)
 Myomectomy (fibroids)
 Tx vaginal infections (trichomoniasis, yeast, bacterial vaginosis)
 Artificial Insemination (insert sperm into uterus/cervix)

In vitro fertilization (IVF): fertilize ovum w. sperm in lab & reinsert (~ 40
hrs). Removed by laparoscopy.
Alternatives to Childbirth:
 Child-free living – allows for freedom, travel, careers, etc.
 Adoption – may take long time, costly
 Surrogate Motherhood – complicated legal & ethical
issues may develop (woman may use own eggs or
donated ova/sperm)
15% infertility cases in USA:
Approx. 40% d/t male factors:
 1/2 of these irreversibly infertile. Others treatable
Approx. 60% d/t female factors:
 ~ 20% - 30% - ovulatory failure (hormonal)
 ~ 20% - 40% - tubal, uterine, vaginal problems (blocked
tube, fibroids, endometriosis , PID, etc.)
Endocrine Problems – Normal hormone activity needed for
ovulation & development of healthy endometrium.



Any dysfunction of pituitary, thyroid, adrenals, pancreas
& ovaries can alter ovulation. Uncontrolled DM may lead
to recurrent miscarriage. ex. PCOS
Hypo or hyperthyroidism also problem.
Attempt to correct disorder
Structural Disorders
 Bicornate uterus; 2 horns. DES exposure. May need IVF.
 Uterine Fibroids - removed with myomectomy or
 May cause ↑ bleeding & prevent conception. May need
hysterectomy
II. Male Factors
Primary Causes of Male Infertility: Impaired sperm
production/mobility/delivery; Testosterone deficiency (hypogonadism).
Can be congenital or acquired.
Problems in Sperm Production
 Average # deposited is 70 million/ml in 2-6 ml.
 Sperm count 20 million or less in 2-6 ml. suggests inadequate production.
Causes:
 Infections - HPV, gonorrhea, chlamydia, epididymitis, testicular
inflammation (orchitis) [mumps as adult]
 High fever from prolonged elevation of scrotal temperature; can cause
irreversible infertility if before puberty
 Diseases (cystic fibrosis, sickle cell anemia); Testicular Cancer
 Testosterone deficiency - disorder in hypothalamic-pituitary-gonadal axis .
 Testosterone production ^ rapidly with puberty & decreases > age 50.
 Men with obesity, diabetes, HTN may be 2X as likely to have low
testosterone levels.
Continued:
Mechanical Factors:
Variocele - varicose vein in spermatic cord. Blood does not cool poor spermatogenesis.
“Variocele Ligation” – improves sperm motility; not useful if sperm
count < 10 mill/ml.
Undescended Testicles (Cryptorchism) Correct with surgery.
 If testicles stay in abdominal cavity during puberty (irreversible)
 Absence of one/both testicles (anorchism)
 Injury/testicular trauma - trigger immune response (antibodies)
impairs sperm: can’t swim thru cervical mucus or penetrate ovum.
 Environmental Influences: Exposure to radiation, chemicals,
chemotherapy. Excessive smoking & ETOH, Drugs (antihypertensives & marijuana), DES exposure; Malnutrition, stress, hot
tubs.
Problems with Sperm Mobility – Greater than 60% of sperm per
ejaculate should be motile for effective fertility.
Factors that may affect mobility:

Decreased Testosterone

Infection (gonorrhea, chlamydia)

Prostate Disease
Problems with Sperm Transport:
 Obstruction d/t scar tissue; secondary to infections [gonorrhea],
injury to Vas Deferens or Vasectomy.
 Retrograde ejaculation: Impaired muscles/nerves in bladder .
Semen flows backward into bladder.
 > bladder surgery/congenital defect in urethra/bladder
 Rare; no ejaculate @ orgasm.
 Retrieve semen in urine [voided or by catheterization].
 Specimen buffered & sperm artificially inseminated.
 Hypospadias – congenital - sperm not high enough in vagina.
Corrected after birth.
III. Combined Problems [Male/Female] – Sexual technique, timing,
immunologic responses.
Sexual Technique/Timing - Provide counseling on:





Position: Female on back with knees flexed for 10-15 min.
Fertility best if intercourse timed around ovulation.
~ 14 days < onset of next menses.
Infrequent intercourse may lower sperm motility.
Frequent : may lower # mature sperm.
Immunologic Factors
 Women: antibodies against partner’s sperm (condoms for 6 mos)
 Men: autoimmune response to own sperm (steroids for sev. mos)
H & P: Both partners
 Past/Present Health, Family, Social, Sexual, Reproductive, Risk
factors, Illnesses, immunizations, allergies, hospitalizations,
accidents, injuries, medications, habits.
 Support systems, occupational, educational, financial status.
 How long attempting pregnancy?
Review of Systems (ROS): Both Partners
 Factors Significant for Both Partners: Exposure to radiation/toxic
substances (lead); drugs, alcohol, marijuana, antihypertensives;
STI’s; Maternal DES (diethylstilbestrol) exposure.
PE of both partners
Management of Female Infertility
Infections: Terazol (yeast); Metronidazole (BV, trich)
Endometriosis: Danazol (Danocrine) – suppresses ovulation, FSH/ LH, & menstruation.
Stops endometrial tissue growth. Side effects: wt. gain, hot flashes
After stopping med. menses resumes 1-6 wks. OR…
 Oral contraceptives continuously to suppress ovulation & tx endometriosis.
 Surgical removal – for moderate to severe disease [laparoscopy]
Cervical Problems
 Estrogen Therapy – before ovulation for few months to enhance quality/quantity of cervical
mucous.
 Cryosurgery – freeze surface of cervix; or recurrent cervicitis.
Endocrine Problems – Ex: Hypothyroid – replacement therapy [Synthroid]
Hyperthroid – surgery, radioiodine, meds.
Fallopian Tube Problems - Infections, adhesions, endometriosis.
 Tx infections: Terazol, Metronidazole
 Hysterosalpingogram may unblock tubes (3%) with procedure.
 Lysis and excision of adhesions - with microsurgery. CO2 laser used for tubal occlusion.
Management of Male Infertility
Lifestyle Changes – Avoid heat sources, radiation/chemicals,
ETOH/drugs, tobacco.
Hormone Tx – Clomid or testosterone may ^ sperm count.
Artificial Insemination: If above fails, artificial insemination with partner’s
sperm.



Also done when cervical environment hostile to sperm.
Sperm are in highest concentration and most motile in 1st few
drops of semen; ejaculate is split and 1st fraction saved.
Multiple first fraction split ejaculates combined & inseminated.
Impotency – failure to have erection. Can occur during infertility
(need to perform). Supportive, non-judgmental atmosphere
with reassurance - may be temporary. Counseling (high school
years) - ^ drug/alcohol use occurs.
Newer Techniques in Managing Infertility
In Vitro Fertilization (IVF)
 Fertilization of mature ovum in lab & re-implantation of
zygotes into uterus via laparoscopy. Fallopian tubes
blocked in IVF candidates. Sperm sample must be
normal. Costly. Success rate 20%. Not covered by
insurance. Eggs can be frozen and fertilized later
Gamete Intrafallopian Transfer (GIFT) Procedure
 Mature oocytes aspirated from female. Oocytes loaded
into catheter with 100,000 washed sperm; contents
placed in fimbrated end of fallopian tube via
laparoscopy. More expensive [surgical]
 Dev. in 1984. Success rate 20-27%.
 Advantage over IVF: entire procedure performed during
one laparoscopy & eliminates 2-day lab incubation
period. Avoids potential damage to zygotes.
ZIFT: Zygote Intrafallopian Transfer
 Fertilized zygote/embryo transferred into fallopian tube
instead of uterus.
 Procedure also referred to as tubal embryo transfer
 must have healthy tubes for this to work.
Options for Infertile Couple



If treatments for infertility are unsuccessful, couple faced
with several choices: Discontinue tx and remain childless
OR…..
Adoption – Couple needs to resolve loss of biologic
parenting first so that adoptive parenting can be positive
experience.
Insemination with donor sperm.
Contraception




Motives for use & choice of method unique to
individuals.
Range of alternatives discussed with clients so
fully informed, satisfactory choice can be made.
Nurse should encourage male’s participation in
selection and counseling. If uncomfortable/
unqualified in giving contraceptive information,
provide referral.
Nurses who provide info. should be aware of all
available methods; advantages/disadvantages.
Factors that Influence Contraceptive Choice

Individual’s stage in life cycle

Personal values

Religious, family, cultural background

Expense

Availability of bathroom facilities

Frequency of intercourse

Number of children desired

Risk of pregnancy couple is willing to accept

Presence of illness or physical problems

Level of comfort with body and its functions
Informed Consent
 Client is informed about method. Discuss methods, benefits, risks,
effectiveness, contraindications.
Risks: Nurse discusses:
 Side effects: weight gain, spotting, breast tenderness, nausea…
 Inconvenience; partner dissatisfaction; condoms, ring
Benefits: Non-contraceptive & contraceptive benefits
 Therapeutic effects : reducing risk of PID; reduction in ovarian/uterine CA
 Important to prevent preg.in very high risk women.
Effectiveness – client’s main concern
 Effectiveness Rate – in preventing pregnancy under ideal conditions
 True Effectiveness Rate – decreases because of human error.
** All methods have advantages and disadvantages
SUMMARY OF CONTRACEPTIVE METHODS
Basal Body Temperature (BBT)
 Methodology: Client measures & records BBT on her calendar until
ovulation can be predicted.
 Action: Abstain from sex for several days before expected time of
ovulation & for 3 days after ovulation.
Rhythm Method (aka Calendar Method or Natural Family Planning
 Methodology: Client uses calendar to calculate fertile/infertile
phases of menstrual cycle.
 Action: Abstain from sex during fertile period.
Cervical Mucus Method (also called Ovulation Method or Billings
Method)
 Methodology: Client assesses cervical mucus for changes in
wetness, color, & clearness throughout menstrual cycle until
ovulation can be predicted by cond.of mucus. Spinnbarkeit
 Action: Abstain from sex when mucus wet, clear, & stretchy.
Symptothermal Method
 Client assesses & records information about primary signs (Cycle
days, cervical mucus changes) & secondary signs ( ↑ libido,
abdominal bloating) until ovulation can be predicted.
 Abstain from sex for few days before expected ovulation & for 3
days after sex.
Situational Contraceptives
 Coitus Interruptus (Withdrawal): Male withdraws from vagina &
ejaculates away from woman’s external genitalia. One of least
reliable methods .
Mechanical Contraceptives
Male Condom: Condom covers penis & prevents sperm from entering
birth canal. Man applies condom to erect penis before vulva/vaginal
contact. Most popular method of male contraception.
Female Condom: fits over cervix & covers part of external genitalia &
base of man’s penis; prevents sperm from entering birth canal.
Woman inserts condom before sex. Not popular.
Diaphragm



Methodology: Spermicide-filled diaphragm covers cervix
preventing sperm from entering birth canal.
Woman fills diaphragm with spermicidal cream & inserts
it into vagina before sex.
Must be left in place for 6 hours > sex; Re-fit with wt.
gain or loss.
Cervical Cap




Method: Cup-shaped device filled with spermicidal
cream fits snugly over cervix; held in place by suction.
Prevents sperm from entering birth canal.
Insert similar to diaphragm.
May be left in place for up to 48 hours.
Insert @ least 20 minutes before inter. & leave in @
least 4 hrs. after sex
Sponge (back on market)
Douching
 Method: Client douches with saline solution
directly > intercourse. * Ineffective: not
recommended. May facilitate conception by
pushing sperm farther up birth canal.
Creams, Jellies, Foams, Vaginal Film,
Suppositories
 Method: Substances destroy/immobilize sperm.
Action: Client inserts into vagina before inter.
 NOTE: Spermicides minimally effective when
used alone; effectiveness ↑ when used with
diaphragm, cervical cap, or condom
 Leave in for 6 hours > sex.
Oral Contraceptives
Combination estrogen [20mcg - 35mcg] & progesterone.
[OC’s inhibit release of ovum & maintains cervical mucus
that is hostile to sperm]
 * Take family/medical hx
 RISK: Thrombophlebitis.
 Contraindicated in women with HTN, over 35 & smoking,
hx breast, ovarian, uterine CA.

Take hormone pills for 21 days, takes placebo for 7 days,
then restart next cycle of pills. To be effective - should be
taken within 1 hour same time each day. Some antibiotics
decrease OC effectiveness – use condoms.

No protection against STD’s – TEACH: consistent
condom use. Double up dose next day if pill is missed.
OC CONT.
 ^ risk of blood clots, esp. in smokers & women over 35
 breakthrough bleeding
 Menstrual cycle & fertility return soon after stopping pill
[99% of 187 women taking Lybrel for 1 year] within 90
days - recent study by Wyeth] Replacing Seasonal.
(BTB 4x/year)
Combination hormones other than Oral…
 Vaginal Ring [once/month]
 Ortho-Evra [patch] once/week
Long-Acting Progestin:
Depo-Provera
Method: 150 mg. IM Injection - ceases ovulation & thickens cervical
mucus to block sperm penetration.
 Effective for 3 months. 4x/yr. Return of fertility delayed for ~9 mos.
 Research shows: significant decrease in bone mass in all females
especially teens.
Counsel:
 Calcium in diet; Weight bearing exercises.
Use limited to 2-3 years; recommend IUD in monogamous couples;
Bone density scan for continued use > 2-3 yrs.



Subdermal Implants (Norplant); no longer used in US;
high rate of infection.
Implanon - single rod available. Good for 3 years; uses
progestin only.
Intrauterine Device (IUD)
Method: IUD immobilizes sperm & impedes their
progress from cervix through uterus to fallopian tubes.
Also causes inflammatory response of endometrium;
spermicidal effect.
 IUD inserted by MD/NP into uterus, String visible at
cervix.
 Check for string > each menses.
 Can perforate uterus
“Mirena” has hormones; good for 5 yrs.
“Copper T” [Paraguard] (10-12 years)
 Multiple cases of STI’s [gonorrhea, chlamydia] can
cause PID; recommended for monogamous couples
only.

Emergency Contraception: Plan B (OTC – 18 yrs or older)
Within 72 hours of unprotected sex. Does not cause abortion if
implantation has occurred.
Operative Sterilization
Vasectomy
 Method: Vas deferens on both sides of scrotum
surgically severed, interrupting flow of sperm from
epididymis. Often can’t be reversed d/t scarring. Semen
will not contain sperm.
Tubal Ligation
 Method: Fallopian tubes are surgically severed
preventing ovum & sperm from meeting. Can be
reversed; costly. May not be covered by insurance.
Reversal has ^ rate of ectopic preg.