Infertility

inability to achieve conception after one year
of unprotected intercourse.
Factors in the Male
1. Abnormalities of the Sperm
2. Abnormal erections
3. Abnormal ejaculation
4. Abnormalities of seminal fluid
5. Obstructed genital tract
6. Normal hormones -- androgens
Factors in the Female
A woman’s fertility depends upon:
1.
FAVORABLE CERVICAL MUCUS
2.
CLEAR PASSAGE BETWEEN CERVIX AND TUBES
3.
PATENT TUBES WITH NORMAL MOTILITY
4.
OVULATION AND RELEASE OF NORMAL OVUM
5.
ENDOMETRIUM PREPARED FOR IMPLANTATION
Preconception Counseling
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Risk for birth defects
– Age of woman
– Family history
Diet & avoidance of teratagens
History & physical
Preconception Counseling
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History
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Age at menarche & characteristics of menstrual cycles
Previous pregnancies/complications
Contraceptive measures
Previous surgeries
Pattern of intercourse related to menstrual cycle
Exposure to toxins
Physical
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Endocrine disturbances
Cranial tumors
Undiagnosed chronic diseases
Assessment of reproductive organs (structural defects, infection, cysts)
Laboratory – clotting studies
Answer this!
During assessment, the nurse discovers that the patient’s
medical history includes a ruptured appendix and
resulting peritonitis several years ago.
Why might this data be pertinent to the patient’s
infertility problem?
a. the infection may have caused sterility
b. resulting scarring and adhesions may
have caused tubal blocking
c. the appendix plays an important role in
tubal functioning
Usually start from the non-invasive tests
to the more invasive
Evaluation of Ovulatory Functions
 Basal Body Temperature
Teach the woman to assess for the drop and
then rise in her temperature as ovulation occurs
Look for the check-mark on the graph.
Teach about factors that may alter temperature:
infection, fatigue, less than 3 hours of sleep,
awakening late, sleeping in a heated waterbed
or under a heating blanket, jet lag.
Monitor BBT for 3 - 4 months to be effective.
Basal Body Temperature Record
Hormonal Function Testing
Gonadotropins (FSH and LH) used for ovulation
prediction.
* assess LH surge that should occur immediately
before ovulation
Progesterone assays – Indicates ovulation and corpus
luteum functioning.
* measured toward the end of the cycle to assess if
the levels remain high.
Endometrial Biopsy – Assessment of the endometrium
has the nutrients and is thick.
* usually done toward the end of the cycle to assess
secretory function
Transvaginal Ultrasound – best used for follicular
monitoring.
ENDOMETRIAL BIOPSY
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Procedure:
A sample of the endometrium is removed and sent to the lab
for study.
*This test is performed after ovulation during the luteal phase
of the menstrual cycle about 2 - 4 days before the expected
menses.
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Purpose:
Assess the corpus luteum and the receptivity of the
endometrium for implantation. (Did it make a good home?)
Responding from estrogen and progesterone stimulation.
Cervical Mucus Testing

Ferning Test:
The maze like strands align in a parallel manner to
allow for easy sperm passage during ovulation.
Cervical Mucus Testing
Teach the appearance of the cervical mucus at
various stages of the menstrual cycle. At time of
ovulation becomes thin, watery, clear.
Evaluation of Cervical Factors

Spinnbarkheit
 Teach the woman to assess for stretchability of
the mucus. Put mucus between two fingers and
pull apart and assess stretchability.
At time of ovulation, the mucus should stretch 8-10 mm
POST COITAL EXAMINATION/ Huhner
 Purpose:
Test the ability of the sperm to survive the cervical
barrier and its secretions
 Procedure:
1. Assess time of ovulation and have intercourse
2. Go to health facility within 2 - 8 hours after sex
3. Semen and cervical mucus are retrieved by
aspiration with a catheter and then tested.
 Test for:
quality of cervical mucus, sperm penetration
through the mucus, number of active sperm,
and signs of infection.
Hysterosalpingography
Primarily used to examine women who
have difficulty becoming pregnant by
allowing the radiologist to evaluate
the:
 shape and structure of the uterus
 the openness of the fallopian tubes
 peritoneal cavity for any scarring,
adhesions
Hysterosalpingography
•Reveals tubal
patency/distorted uterus
•Therapeutic by flushing
debris or breaking
adhesions
•Causes: Uterine
cramping and referred
shoulder pain
Laparoscopy
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Under general anesthesia, entry made through an
incision in the umbilical area.
Peritoneal cavity is distended with carbon dioxide
gas
Pelvic organs are visualized with a fiber optic
instrument
Dye can be injected into the uterus and up the
tubes to check patency.
The pelvis can be evaluated for adhesions, cysts,
tumors, and endometriosis
Hysterscopy

Visual inspection of the uterus through the
insertion of a scope through the cervix.

Usually follows a hystersalpingography
Semen Analysis
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Procedure:
• Specimen is collected after 3 - 4 days of abstinence.
• The man ejaculates into a clean, dry specimen
container or condom and takes it to the lab for
study.
• The sperm are examined under microscope within
1 hour of collection
*Make sure not to get the specimen too hot or cold!
Semen Analysis
Assess for:
1. Number, appearance, motility
2. Amount--average ejaculation is about 5 ml. with
a minimum of 20 million sperm/ ml. of fluid
( Normal count is 50 - 200 million/ ml. of fluid)
3. Semen pH 7.2 - 7.8
4. Liquification – usually occurs in 30 min.
5. Fructose
Ask Yourself
In assessing the adequacy of sperm for conception
which of the following is the single most useful
criterion?
a. sperm count
b. sperm appearance
c. sperm motility
d. semen volume
Hormonal Testing
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Testosterone
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LH and FSH
Other Testing
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Urinalysis
Ultrasound
Testicular biopsy
Sperm penetration assay
Surgical Procedures
Surgery used
to
Correct
Obstructions
Correct
Malformations
Treatment for Male and Female
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Treat the underlying cause:
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Infection
Abnormal genital structures
Teach measures that promote fertility- nonmedical therapies.
Try this!
The nurses’ teaching for potentially increasing
fertility would include which of the following
initially?
a. Reduce frequency of intercourse to less than
once a week
b. Clarify the validity of the degree of sexual
satisfaction
c. Instruct them to eliminate any additional
lubrication
Clomiphene Citrate (Clomid)
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Action: stimulates follicular growth by increasing
secretion of FSH and LH
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Success- 40% become pregnant
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Patient Teaching
Take the drug for 5 days starting day 5-9 of
menstrual cycle.
Usually start with 50 mg. and increase to 250 mg.
Side Effects of Clomid
Anti-estrogenic may cause:
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a DECREASE in cervical mucus production
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Hot flashes
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Abdominal Bloating
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Breast Tenderness
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Nausea and Vomiting
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Ovarian enlargement
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Visual Disturbances
Human menopausal gonadotropins
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Human menopausal gonadotropin
Stimulates follicular development. Formed from the
combination of FSH and LH obtained from
postmenopausal women’s urine
Administered IM every day for various times
during the first half of the menstrual cycle. Dose
is based on serum estradiol and ultrasound
finding.
The Woman is taught to give her own injections.
**Drug may overstimulate ovaries and end up with multiple births
Other Pharmacologic Agents
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Bromocriptine (Parlodel) - Acts directly on
prolactin-secreting cells inhibiting their secretion of
prolactin.
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Chorionic Gonadotropins – Stimulates progesterone
production by the corpus luteum.
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GnRH agonists – Stimulates release of FHS and LH
from the pituitary gland.
(See Table 10-4 on page 208)
Therapeutic Insemination
 May use either the husband’s Semen (THI) or that
of a donor (TDI).
 The conception rate is:
 30% with donor’s semen
 15% with husband’s semen.
 Sperm is “washed” and placed in a cervical cup
and deposited at the cervical os or directly in the
uterus with a small catheter.
 The woman is to remain in supine position with
hips elevated for about 20 - 30 minutes
In Vitro Fertilization
Used in Couples in which:
Woman has blocked or
damaged fallopian tubes
Male sperm count is low
Infertility is long-term and
unexplained
In Vitro Fertilization Procedure
1.
2.
Ovulation is induced using
fertility drug (Lupron, Follistim,
Gonal F, Clomid) Ovarian
function is monitored. Pregnly
or Profasi given to assist with
release of egg from corpus
luteum.
Ripened, mature ova are
aspirated from the ovaries
during laparoscopy
In Vitro Fertilization
3. The ova are incubated for at least
8 hours then transferred to culture
media
4. Sperm that have been capicitated are
added to the ova in a perti dish
5. After fertilization, zygotes are
allowed to grow and then transferred
to the uterus through a catheter.
6. The woman may be give Progesterone
injections to enhance receptivity of
the endometrium to implantation.
Reminder!!
Fresh sperm cannot fertilize an ovum, it must be
capicitated “washed” first.
Capicitation is the act of separating the sperm from
the semen and diluting it.
This process:
 removes many of the antibodies that interfere with
sperm motility and ability to penetrate the ovum
 removes prostaglandins
 allows for concentration of sperm
Gamete Intrafallopian Transfer
GIFT
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Ovulation is induced similar to IVF
The ova are retrieved and they are placed directly
into the fallopian tube along with the male’s
sperm.
Fertilization to take place in the fallopian tubes
Success rates are higher
More acceptable since fertilization does not occur
outside the body
Tubal Embryo Transfer
Zygote Intrafallopian Transfer
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Fertilization occurs outside body
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Placed in the fallopian tubes so can enter the uterus
naturally for implantation
Microsurgical Assisted Fertilization
1.
Small slit made into zona
pellucida cells that surround
the ovum to allow sperm to
gain access
2.
Intracytoplasmic sperm
injection – sperm injected
directly into the egg.
Reproductive Techniques
• Legal/ethical considerations.
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Storage of ova, sperm & fertilized eggs
Surrogacy
Availability to treatment to all
Not implanting live embryos with genetic deficiencies
Reduction of multiple fetus
• Psychological impact must be discussed. Are
both of the couple in favor of this choice of
conception?
• Semen is screened for HIV and other diseases
Advanced Reproductive Techniques can cause
much controversy and criticism
 Major psychological and economic strain on the couple
Cost
Frequent office visits
Multiple therapies
Unsuccessful treatments
 Chance of multifetal pregnancies
 Decision of selective reduction
 Influenced by the couples cultural, psychosocial
background.
THE END