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Infertility • A lack of conception despite unprotected sexual intercourse for at least 12 months • Primary vs. Secondary Psychological and economical impacts What are they? What is normal? • Female ▫ Favorable cervical mucus ▫ Clear passage between cervix and tubes ▫ Patent tubes with normal motility • Male ▫ Normal semen ▫ Unobstructed genital tract ▫ Normal genital tract functioning ▫ Normal hormones 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 Hormonal assessments Endometrial biopsy Transvaginal ultrasound Basal Body Temperature Record Cervical Mucus Testing Spinnbarkheit 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. POST COITAL EXAMINATION 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 Instill a radiopaque dye into the uterine cavity under pressure The substance fills the uterus, tubes, and spills into the peritoneal cavity Viewed with an xray Hysterosalpingography •Reveals tubal patency/distorted uterus •Therapeutic by flushing debris or breaking adhesions •Causes: Uterine cramping and referred shoulder pain Hysteroscopy • Visual inspection of the uterus through the insertion of a scope through the cervix • Usually follows a hysterosalpingography Laparoscopy 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 Semen Analysis 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 LH, FSH, Testosterone Sperm analysis Infection Testing Urinalysis Cultures Structural Testing • Ultrasound testing • Testicular biopsy • Sperm penetration assay Treatment for Male and Female Treat the underlying cause: • • • Infection Abnormal genital structures Teach measures that promote fertilitynon-medical 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) • Action: stimulates follicular growth by increasing secretion of FSH and LH • Success- 40% become pregnant • 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: • a DECREASE in cervical mucus production • Hot flashes • Abdominal Bloating • Breast Tenderness • Nausea and Vomiting • Ovarian enlargement • Visual Disturbances Pergonal: Human menopausal gonadotropins 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 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 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 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. 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. 2. 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. Gamete Intrafallopian Transfer GIFT • 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 • Fertilization occurs outside body • 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. • • • • • 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.