Infertility
Penne Mott
Diagnosis
• After one year of frequent, unprotected
sexual intercourse there is no conception or
maintenance of pregnancy
• 15 – 30% couples in US
Etiology
• Endometriosis
– Interference with tubal patency
– Endometrial fragility
– Adhesions that displace the ovaries
• Treatment
– Laparoscopy
– Cautery
– Hormonal Rx
Etiology
• Tubal Blockage
– Scarring (PID)
– Fibroids
• Uterine Problems
– Tumors
– Congenital Anomalies
Etiology
• Anovulation
– Genetic – Turners Syndrome, Hypogonadism
– Problems with the Hypothalamus
• Pituitary-ovarian hormonal feedback mechanisms
– Hypothyroidism
– Stress
– Decreased body weight
Etiology
• Anovulation
• Treatment
– Menotropins – Pergonal, Repronex
(medications made up of gonadotropins
extracted from the urine of postmenopausal
women)
– GnRH Agonist – Lupron, Synarel (synthetic
versions of GnRH’s)
Etiology
• Cervical Mucus Problems
– Vaginal Infections
– Hormone Deficiencies
• Treatment
– HRT
– Cryosurgery
– Guaifenesin
Etiology – Male Factors
• Varicocele – varicose of swollen vein in the
testicle
• Cryptorchidism – undescended testicle at
birth
• Restrictive undergarments
• Occupational exposure to heat
• Working in a seated position
Etiology – Male Factors
• Immunological Factors
– Autoimmune reaction
– Production of antibodies that destroy sperm
• Obstruction in Sperm Transport
– Mumps
– Epididymitis
– STD’s
Assessment – Male
History
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General Health
Nutrition
Alcohol, drug or tobacco use
Congenital health problems - hypospadias
or cryptorchidism
• Illnesses such as mumps orchitis, UTI’s, or
STD’s
Assessment – Male
History
• Operations – surgical repair of a hernia
• Current illnesses – endocrine
• Past and current occupation & work habits
(Does job involve sitting at a desk all day or
x-ray exposure)
Assessment – Female
History
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•
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Current or past reproductive tract problems
Endocrine problems
Abdominal or pelvic surgeries
Use of vaginal douches or medications
(interfere with pH)
• Occupational exposure to x-ray or toxic
substances
Assessment – Female
History
• Menstrual History
– Age of menarche
– Length, regularity, & frequency of menstrual
periods
– Amount of flow
– Dysmenorhea / PMS
– Contraceptive use
– Hx. Previous pregnancies or abortions
Diagnostic Studies –
Female
• Basal Body Temperature (BBT)
– Oral temp taken each day prior to arising
– Results are graphed
– Sudden dip occurs the day prior to ovulation &
is followed by a rise of 0.5 –1.0 degrees F,
which indicates ovulation
Diagnostic Studies –
Female
• Serum Hormone Testing
– Venous blood is drawn to assess levels of FSH
and LH
– These are indicators of ovarian function
Diagnostic Studies –
Female
• Postcoital Exam
– Couple has sexual intercourse 8 – 12 hours prior to
exam, 1-2 days before expected ovulation
– A 10 cc syringe with catheter attached is used to collect
a specimen of secretions from the vagina
– Secretions are examined for: S/S infection, # of active
& non-motile sperm, sperm-mucus interactions, &
consistency of cervical mucus
Diagnostic Studies –
Female
• Endometrial Biopsy
– Paracervical Block to decrease cramping / pain
– Pinch of endometrium obtained to check for a
luteal phase defect (lack of progesterone)
• Pre-procedure Care
– Instruct the client to undress below the waist
– Assist on exam table
Diagnostic Studies –
Female
• Endometrial biopsy
• Post-procedural Care
– Provide sanitary napkins
– Assess for vaso-vagal response – fainting
caused by hypotension
Diagnostic Studies –
Female
• Hysterosalpingogram (HSG)
– Detects uterine anomalies (septate, unicornate,
bicornate)
– Detects Tubal anomalies or blockage
– Iodine-based radio-opaque dye is instilled
through a catheter into the uterus and tubes to
outline these structures and x-rays are taken to
document findings
Diagnostic Studies –
Female
• Laparoscopy
– General or epidual anesthesia
– Abdomen is insufflated with carbon dioxide
– One or more trochars are inserted into the
peritoneum near the umbilicus & symphysis
pubis
– Laparoscope visualizes structures in the pelvis
– Can perform certain surgical procedures
Diagnostic Studies –
Male
• Semen analysis
– Ejaculates into a specimen container
– Ejaculate examined for:
• Number
• Morphology
• Motility
Normal Semen Analysis Results
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Volume >2.0 mL
pH 7.0 – 8.0
Total sperm count >20 million per mL
Motility 50% or greater
Normal forms 50% or greater
Diagnostic Studies –
Male & Female Partner
Anti-sperm antibody evaluation of cervical
mucus and ejaculate are tested for
agglutination
Indication that secretory immunological reactions
are occurring between cervical mucus and
sperm
Psychological Factors
• Shame
• Guilt
• Stages of grief
• Facilitate communication
• Listen
• Support Groups
Priority Nursing Diagnosis
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Compromised family coping
Knowledge deficit
Anxiety
Situational low self-esteem
Implementation and
Collaborative Care
• Educational Needs
– Perform various procedures (semen collection)
– Meaning of the results of tests and assessments
– Self-monitoring during medication
administration
– How assisted reproductive technologies (ART)
are performed
Implementation and
Collaborative Care
• Hormonal Therapy
– How to give SQ and/or IM injections
Implementation and
Collaborative Care
• Medications
– Clomiphene citrate (Clomid, Serophene) – used
to increase FSH and LH secretion, thereby
stimulating ovulation
– One IM dose of HCG may be administered to
stimulate release of the ova from the follicles
Implementation and
Collaborative Care
• Sperm Washing for Intrauterine
Insemination (IUI)
– Ejaculate is centrifuged to concentrate sperm,
which are then rinsed with saline to remove the
seminal fluid
– Sperm are again centrifuged, and then used for
either IVF or Intrauterine artificial insemination
Implementation and
Collaborative Care
• Intrauterine Insemination (a form of
artificial insemination)
– Sperm are collected within 3 hours of colitus
and are inserted via a catheter into the uterus
– Donor sperm may be used
– Identify of the sperm donor is kept confidential
Implementation and
Collaborative Care
• In Vitro Fertilization (IVF)
– Multiple ova are harvested via a large-bore
needle and syringe transvaginally under
ultrasound guidance
– Ova are then mixed with sperm
– Up to 4 of the resultant embryos are returned to
the uterus 2-3 days later
IVF Side Effects
• Cysts on the ovaries
• Multiple births
• Ovarian Hyperstimulation
IVF –
Pre-procedure Care
• Administration of synthetic FSH injections
SQ in the abdomen, thigh or upper arm to
stimulate the ovary to produce multiple ova
for 5 – 6 days prior to the procedure
• Giving sedation for the oval retrieval
procedure
IVF –
Postprocedure Care
• Observation 2 hrs after egg retrieval
• Instructing the woman to limit activity for
24 hrs.
• After embryo placement progesterone
supplementation is commonly prescribed
THINK – Answer the Following
• The client is undergoing ovulation induction
in preparation for IVF. She has business
commitments and wants to know when to
schedule her meetings around the IVF
procedure. What should the nurse tell her?
Case Study
• The client is a 38 year old woman with
primary infertility. The client and her
husband are in today for a first appointment
at the infertility clinic where you work.
Answer the Following
• What medical and surgical history questions
will you ask the woman?
• What medical and surgical history questions
will you ask of the client’s husband?
• When the client asks you what to expect in
the initial assessment of her infertility, how
will you answer?
Answer the Following
• What information about the couple’s sexual
activity do you need to obtain?
• How will the woman’s age affect the
couple’s probable infertility treatment?
Alternatives to Childbirth
• Adoption
• Surrogate mothers
• Childless living