Infertility

1. Infertility Penne Mott

2. Diagnosis • After one year of frequent, unprotected sexual intercourse there is no conception or maintenance of pregnancy • 15 – 30% couples in US

3. Etiology • Endometriosis • Interference with tubal patency • Endometrial fragility • Adhesions that displace the ovaries • Treatment • Laparoscopy • Cautery • Hormonal Rx

4. Etiology • Tubal Blockage • Scarring (PID) • Fibroids • Uterine Problems • Tumors • Congenital Anomalies

5. Etiology • Anovulation • Genetic – Turners Syndrome, Hypogonadism • Problems with the Hypothalamus • Pituitary-ovarian hormonal feedback mechanisms • Hypothyroidism • Stress • Decreased body weight

6. 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)

7. Etiology • Cervical Mucus Problems • Vaginal Infections • Hormone Deficiencies • Treatment • HRT • Cryosurgery • Guaifenesin

8. 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

9. Etiology – Male Factors • Immunological Factors • Autoimmune reaction • Production of antibodies that destroy sperm • Obstruction in Sperm Transport • Mumps • Epididymitis • STD’s

10. Assessment – MaleHistory • General Health • Nutrition • Alcohol, drug or tobacco use • Congenital health problems - hypospadias or cryptorchidism • Illnesses such as mumps orchitis, UTI’s, or STD’s

11. Assessment – MaleHistory • 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)

12. Assessment – FemaleHistory • 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

13. Assessment – FemaleHistory • Menstrual History • Age of menarche • Length, regularity, & frequency of menstrual periods • Amount of flow • Dysmenorhea / PMS • Contraceptive use • Hx. Previous pregnancies or abortions

14. 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

15. Diagnostic Studies – Female • Serum Hormone Testing • Venous blood is drawn to assess levels of FSH and LH • These are indicators of ovarian function

16. 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

17. 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

18. Diagnostic Studies – Female • Endometrial biopsy • Post-procedural Care • Provide sanitary napkins • Assess for vaso-vagal response – fainting caused by hypotension

19. 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

20. 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

21. Diagnostic Studies –Male • Semen analysis • Ejaculates into a specimen container • Ejaculate examined for: • Number • Morphology • Motility

22. Normal Semen Analysis Results • 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

23. 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

24. Psychological Factors • Shame • Guilt • Stages of grief • Facilitate communication • Listen • Support Groups

25. Priority Nursing Diagnosis • Compromised family coping • Knowledge deficit • Anxiety • Situational low self-esteem

26. 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

27. Implementation and Collaborative Care • Hormonal Therapy • How to give SQ and/or IM injections

28. 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

29. 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

30. 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

31. 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

32. IVF Side Effects • Cysts on the ovaries • Multiple births • Ovarian Hyperstimulation

33. 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

34. 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

35. 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?

36. 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.

37. 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?

38. 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?

39. Alternatives to Childbirth • Adoption • Surrogate mothers • Childless living