Republic of the Philippines

ISABELA STATE UNIVERSITY

City of Ilagan, Isabela

COLLEGE OF NURSING

Problems of Infertility

 Infertility is the inability to conceive after 1 year of trying when the female is under 35 and 6 months
when the female is over 35.

 Secondary infertility is when a woman who has been pregnant previously cannot conceive.

 Fecundity is the term used to describe the chance of achieving pregnancy and subsequent live birth
within one menstrual cycle. Fecundity averages 20% in couples who are not experiencing
reproductive problems.

 Sterility is the inability to conceive because of a known condition, such as absence of a uterus

 Subfertility is a lessened ability to conceive

 Cause of infertility in males include environmental agents, problems with sperm production or
transport, low sperm count and motility.

 Causes of infertility in females include problems with the production and transport of ova,
endometriosis, and infections.

 Infertility can affect both genders (females and males).

 Infertility can cause stress and a sense of loss and inadequacy in a relationship.

 A normal fertile couple has a 20% chance of conceiving during each ovulatory cycle. As a woman
ages, infertility increases; therefore women older than age 40 have a 50% decrease in fertility rate

RISK FACTORS

Some of the risk factors for infertility in women are as follows:

Endmetriosis is the implantation of uterine endometrium outside the uterus. The most common sites for
endometriosis are the lower pelvis and bowel. Inadequate endometrium (thinning of the uterine lining
after surgical procedures and inadequate hormonal production) can lead to infertility.

 History of pelvic inflammatory disease  Fibroid tumors

 Hormonal imbalances leading to irregular  Sexually transmitted infections

ovulation
 Age older than 35
 Fallopian tube blockages
  Multiple abortions (miscarriages)

 Smoking and alcohol consumption

 Overweight or underweight (disrupts  Stress (psychological)

hormonal functions)
 Endocrine changes (begins 10 to 15 years
 Chronic diseases (diabetes and thyroid before menopause)
malfunction)

Some of the infertility risk factors for men are as follows:

 Undescended testicles and testicular disorders  Development of autoimmunity that

(surgery and trauma) immobilizes sperm.

 Tight jeans or other tight-fitting pants  Problems in ejaculation or deposition

 Overuse of hot tubs or saunas (high
temperatures)
 Mumps after puberty
 Disturbance in spermatogenesis (production
of sperm cells).
 Obstruction in semineferous tubules, ducts or
vessels preventing spermatozoa.
 Qualitative or quantitative changes in the
seminal fluid preventing sperm motility
(sperm movement)
preventing spermatozoa from being place
close enough to a woman’s cervix to allow
ready penetration and fertilization.
 Exposure to toxic substances (x-rays,
mercury, and lead)
 Heavy alcohol consumption
 Sexually transmitted infections
 Cigarette smoking
 Extended periods of bike riding

CAUSES OF INFERTILITY

Female infertility

 Female infertility can result from dysfunction in all phases of the reproductive process.

 The most critical phases are follicular maturation, ovulation, transport of the ovum through the
fallopian tubes, fertilization of the ovum, nidation (implantation), and growth and development of the
conceptus. These events can take place only if the ovaries, uterus, hypothalamus, and pituitary are
functioning properly. If the activity of any of these structures is disturbed, fertility can be impaired.

Anovulation and failure of follicular maturation

In the absence of adequate hormonal stimulation, ovarian follicles will not ripen and ovulation will not
take place. Frequently, these causes of infertility can be corrected with drugs. The agents used to promote
follicular maturation and/or ovulation are clomiphene, menotropins, follitropins (eg, urofollitropin),
and human chorionic gonadotropin (hCG).

Tubal transport problems

Difficulty with tubal transport usually occurs because scarring developed in the fallopian tubes

This is typically caused by chronic salpingitis (chronic pelvic inflammatory disease)

Pelvic Inflammatory Disease

Is the infection of the pelvic organs (uterus, fallopian tubes, ovaries and their supporting structures)

Can spread further causing pelvic peritonitis.

Can be commonly caused by chlamydia and gonorrhea.

There may be higher incidence with women using IUDs. They are advised to limit the number of their
sexual partners to reduce incidence of STIs

It usually begins with a cervical infection that spreads by surface invasion along the endometrium and
then out to the fallopian tubes and ovaries

It occurs at the end of the menstrual period, because menstrual blood provide excellent growth
medium. A loss of the normal cervical mucus barrier happens at this time which increases the risk for
initial invasion. It can lead to chronic PID if left untreated.

Uterine problems
tumors such as fibromas (leiomyomas) may be a rare cause of infertility if they block the entrance of the
fallopian tubes into the uterus or limit space available on the uterine wall for effective implantation.

Cervical problems

Thickening of the cervical mucus that spermatozoa cannot penetrate

Vaginal problems

Infection of the vagina can cause the pH of the vaginal secretions to become acidotic, limiting or
destroying the mobility of the spermatozoa.

Unfavorable cervical mucus

In the periovulatory period, the cervical glands normally secrete large volumes of thin, watery mucus.
These secretions, which are produced under the influence of estrogen, facilitate passage of sperm through
the cervical canal. If the cervical mucus is scant or of inappropriate consistency (thick, sticky), sperm will
be unable to pass through to the uterus. Production of unfavorable mucus may occur spontaneously or as a
side effect of clomiphene
Hyperprolactinemia

Elevation of prolactin levels may be caused by a pituitary adenoma or by disturbed regulation of the
healthy pituitary. Amenorrhea, galactorrhea, and infertility may all occur in association with excessive
prolactin. The mechanism by which hyperprolactinemia impairs fertility is unknown. Hyperprolactinemia
can be treated with cabergoline, bromocriptine, and other dopamine agonists.

Endometriosis

Endometriosis is a condition in which endometrial tissue has become implanted outside the uterus,
usually on the ovaries, pelvic peritoneum, or rectovaginal septum. These endometrial implants respond to
hormonal stimulation in much the same way as the normally situated endometrium.

The mechanism by which endometriosis reduces fertility is not always clear. In some cases, infertility
results from ovarian or tubal adhesions that impede transport of the ovum. However, when endometriosis
is mild, a visible cause of infertility may be absent.

Endometriosis can be treated with surgery, drugs, or both.

Polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a combined endocrine-metabolic disorder characterized by

androgen excess and insulin resistance. Symptoms include irregular periods, anovulation, infertility, acne,
and hirsutism.

PCOS can be treated with lifestyle changes and drugs. The goal is to restore regular menstruation and
ovulation, reverse hyperandrogenism (and thereby eliminate acne and hirsutism), and decrease the long-
term risk of diabetes, cancer, and heart disease.

Male infertility

 For about 50% of infertile couples, failure to conceive is due entirely to reproductive dysfunction in
the male.

 The most common cause is decreased density or motility of sperm, or semen of abnormal volume or
quality.

 The most obvious cause is erectile dysfunction (ED). In most cases, infertility in males is not
associated with an identifiable endocrine disorder. Unfortunately, with the exception of ED, male
infertility is generally unresponsive to drugs.

Inadequate sperm count

The sperm count is the number of sperm in a single ejaculation or in a mm of semen.

The minimum sperm count considered normal is 20million per mm of seminal fluid, or 50million per
ejaculation
At least 50% of sperm should be motile, and 30% should be normal in shape and form.

Factors that can lead to low sperm count are:

 Inappropriate temperature

 Cryptorchidism (undescended testes) is a congenital disorder that may lead to lowered sperm
production if surgical repair of this condition is not completed until after puberty or if the spermatic
cord became twisted after surgery.

 Varicocele (varicosity of the spermatic vein) it can increase the temperature in the testes, which can
slow or disrupt spermatogenesis. Surgery is needed.

*Men who are exposed to radioactive substances on the job should have adequate protection of
the testes.

*When undergoing pelvic radiography, men should always be furnished with a protective lead
testes shield.

Obstruction or Impaired sperm motility

Obstruction may occur at any point along the pathway that spermatozoa must travel to reach the outside
(semineferous tubules, epididymis, vas deferens, ejaculatory duct and urethra)

Factors:

 Mumps orchitis (testicular inflammation and scarring due to mumps virus)

 Epididymitis (inflammation of the epididymis)

 Tubal infections (gonorrhea or ascending urethral infections)

 Hypertrophy of the prostate gland (begins in many men at age 50)

 Pressure from the enlarged gland on the vas deferens

 Infection of the prostate or infection of the seminal vesicle (spread from UTI) can alter the
composition of the seminal fluid enough to reduce sperm motility.

Ejaculation problems

Psychological problems, debilitating diseases such as cerebrovascular accident or parkinson’s disease and
some medication (e.g certain antihypertensive agents) may result in Erectile Dysfunction (formerly called
impotence)

Hypogonadotropic hypogonadism
A few males may be incapable of spermatogenesis owing to insufficient gonadotropin secretion. In these
rare cases, drugs may help. If the gonadotropin deficiency is only partial, sperm counts can be increased
using hCG (alone or in combination with menotropins). If the deficiency is severe, treatment with
androgens is required. If therapy with hCG and menotropins is intended, the patient should be informed
that treatment will be both prolonged (3 to 4 years) and expensive.

Erectile dysfunction

Inability to achieve erection is the most conspicuous cause of male infertility. Sildenafil [Viagra] and
other drugs for ED.

Idiopathic male infertility

Idiopathic infertility is defined as infertility for which no cause can be identified.

DIAGNOSTICS

Basic infertility testing involves only three tests: semen analysis in the male, and ovulation monitoring
and tubal patency assessment in the female.

Sperm penetration assay and antisperm antibody testing

For impregnation to take place, sperm must be mobile to reach the ova.

They are carried out to determine whether a man’s sperm can penetrate the ovum effectively.

Ovulation monitoring

The least cost way to determine ovulation pattern is to record Basal Body Temperature for at least 1
month.

Monitoring your cycle through ovulation predictor kits (OPKs), charting basal body temperature (BBT),
and/or examining cervical mucus can greatly increase your odds of becoming pregnant during a
particular cycle.

Ovulation cycle tracking is a good first step towards maximising your chance of conceiving naturally.
With ovulation cycle monitoring, there's no need for invasive fertility treatments, medication or
surgery.Ovulation tracking is a simple process that helps you identify your most fertile days of each
month.

Tubal patency

Can be assessed in a number of ways, both UTZ and X-ray to assess not only the fallopian tubes but also
the depth and consistency of the endometrial lining.

 Sonohysterectography designed for inspecting the uterus.

 Hysterosalpingography a radiologic examination of the fallopian tubes using a radiopaque medium,
is the most frequent way of assessing tubal patency

Uterine endometrial biopsy

Used as a test for ovulation or to reveal and endometrial problem such as a luteal phase defects

Hysteroscopy

Laparoscopy

Assessment of Female Infertility

Evaluation for infertility should be offered to couples who have failed to become pregnant.

Investigation of impaired fertility begins for the woman with a complete history and physical
examination. A complete general physical examination should include height and weight and estimation
of BMI. Both obesity and being underweight are associated with anovulation disorders.

Signs and symptoms of androgen excess such as excess body hair or pigmentation changes should be
noted.

The general physical examination is followed by a specific assessment of the reproductive tract. A history
of infections of the genitourinary tract and any signs of infections, especially STIs that could impair tubal
patency, should be assessed. Bimanual examination of internal organs may reveal lack of mobility of the
uterus or abnormal contours of the uterus and tubes. A woman may have an abnormal uterus and tubes as
a result of congenital abnormalities during fetal development). These uterine abnormalities increase risk
for early pregnancy loss.

Diagnostic Testing

The basic infertility survey of the female involves evaluation of the cervix, uterus, tubes, and peritoneum;
detection of ovulation; and hormone analysis.

Previous status regarding ovulation can be evaluated through menstrual history, serum hormone studies,
and use of an ovulation predictor kit.

If the woman is over age 35, the clinician may choose to assess “ovarian reserve” or how many potential
ova remain within the ovaries. A common evaluation of ovarian reserve is measurement of follicle-
stimulating hormone (FSH) levels on the third day of the menstrual cycle.

The uterus and fallopian tubes can be visualized for abnormalities and tubal patency through
hysterosalpingogram (x-ray film examination of the uterine cavity and tubes after instillation of
radiopaque contrast material through the cervix).

If the woman is at risk for endometriosis (implants of endometrial tissue outside of the uterus) or
adhesions, diagnostic laparoscopy may be indicated.
Assessment of Male Infertility

The systematic investigation of infertility in the male patient begins with a thorough history and physical
examination. Assessment of the male patient proceeds in a manner similar to that of the female patient,
starting with noninvasive tests.

Diagnostic Testing and Semen Analysis.

The basic test for male infertility is semen analysis. A complete semen analysis, study of the effects of
cervical mucus on sperm forward motility and survival, and evaluation of the ability of the sperm to
penetrate an ovum provide basic information. Sperm counts vary from day to day and depend on
emotional and physical status and sexual activity. Therefore a single analysis may be inconclusive. A
minimum of two analyses must be performed several weeks apart to assess male fertility.

Semen is collected by ejaculation into a clean container or a plastic sheath that does not contain a
spermicidal agent. The specimen is usually collected by masturbation following 2 to 7 days of abstinence
from ejaculation. The semen is examined at the collection site or taken to the laboratory in a sealed
container within 2 hours of ejaculation. Exposure to excessive heat or cold is avoided.

If results are in the fertile range, no further sperm evaluation is necessary. If results are not within this
range, the test is repeated. If subsequent results are still in the subfertile range, further evaluation is
needed to identify the problem.

Semen Analysis:

• Semen volume at least 1.5 L

• Semen pH 7.2 or higher

• Sperm density greater than 15 million/mL

• Total sperm count greater than 39 million per ejaculate

• Normal morphologic features greater than 4% (normal oval)

• Motility (important consideration in sperm evaluation)—percentage of forward-moving sperm

estimated with respect to abnormally motile and nonmotile sperm, 40%

• Liquification—usually within 15 minutes but no longer than 60 minutes

Hormone analyses are done for testosterone, gonadotropin, FSH, and luteinizing hormone (LH).

The sperm penetration assay and other alternative tests can be used to evaluate the ability of sperm to
penetrate an egg.

Testicular biopsy may be warranted.

Scrotal ultrasound can be used to examine the testes for presence of varicoceles and identify
abnormalities in the scrotum and spermatic cord.
Transrectal ultrasound is used to evaluate the ejaculatory ducts, seminal vesicles, and vas deferens.

MANAGEMENT

Nonmedical Treatments

Both men and women can benefit from healthy lifestyle changes that result in a BMI within the normal
range; moderate daily exercise; and abstinence from alcohol, nicotine, and recreational drugs.

For the woman with a BMI >27 and polycystic ovary syndrome, losing just 5% to 10% of body weight
can restore ovulation within 6 months. Anovulatory women with a BMI <17 who have eating disorders or
intense exercise regimens benefit from weight gain.

Simple changes in lifestyle may be effective in the treatment of subfertile men. Only water-soluble
lubricants should be used during intercourse because many commonly used lubricants contain
spermicides or have spermicidal properties.

High scrotal temperatures can be caused by daily hot tub baths or saunas that keep the testes at
temperatures too high for efficient spermatogenesis.

Pharmacologic therapy

For female infertility is often directed at treating ovulatory dysfunction by either stimulating or enhancing
ovulation so more oocytes mature. These medications include

(a) clomiphene citrate as initial therapy for many women with intermittent anovulation;

(b) a combination of clomiphene and metformin for women with anovulation and insulin resistance;

(c) human menopausal gonadotropin (HMG), FSH, and recombinant FSH (rFSH) to stimulate follicle
formation in women who do not respond to clomiphene therapies;

(d) human chorionic gonadotropin to induce ovulation when follicles are ripe,

(e) gonadotropin-releasing hormone (GnRH) agonists at the beginning of a cycle to sequence HMG
therapies,

(f) progesterone to support the luteal phase of the cycle, and

(g) bromocriptine (Parlodel) for women who have excess prolactin

Clomiphene citrate (with the possible addition of metformin) is often the initial pharmacologic treatment
of the infertile woman because it is inexpensive and the side effect profile is less than other medications
that induce ovulation.

Drug therapy may be indicated for male infertility. As with women, problems with the thyroid or adrenal
glands are corrected with appropriate medications. Infections are identified and treated with
antimicrobials. FSH, HMG, and clomiphene may be used to stimulate spermatogenesis in men with
hypogonadism.

Men who do not respond to these therapies are candidates for intracytoplasmic sperm injection (ICSI),
which is a procedure that injects sperm directly into the egg as part of IVF. ICSI has enabled men with
very low sperm counts to achieve biologic reproduction.

Surgical Therapies

A number of surgical procedures can be used for problems causing female infertility.

Hysterosalpingography is useful for identification of tubal obstruction and also for the release of blockage

During laparoscopy delicate adhesions may be divided and removed, and endometrial implants may be
destroyed by electrocoagulation or laser.

Laparotomy and microsurgery may be required for extensive repair of the damaged tube. Prognosis
depends on the degree to which tubal patency and function can be restored.

In women with uterine abnormalities reconstructive surgery (e.g., the unification operation for bicornuate
uterus) can improve the ability to conceive and carry a fetus to term.

Surgical removal of tumors or fibroids involving the endometrium or muscular walls of the uterus could
also improve the woman’s chance of conceiving and maintaining a pregnancy to viability, depending on
the location and size of the fibroid or tumor.

Surgical treatment of uterine tumors or maldevelopment that results in successful pregnancy usually
necessitates birth by cesarean surgery near term gestation because the enlarging uterus can rupture as a
result of weakness in the area of reconstructive surgery.

Chronic inflammation and infection can be eliminated by radial chemocautery (destruction of tissue with
chemicals) or thermocautery (destruction of tissue with heat, usually electrical) of the cervix, cryosurgery
(destruction of tissue by application of extreme cold, usually liquid nitrogen), or conization (excision of a
cone-shaped piece of tissue from the endocervix).

When the cervix has been deeply cauterized or frozen or when extensive conization has been performed,
the cervix may produce less mucus. Therefore the absence of a mucus bridge from the vagina to the
uterus can make sperm migration difficult or impossible.

Therapeutic intrauterine insemination may be necessary to carry the sperm directly through the internal os
of the cervix.

Surgical procedures may also be used for problems causing male infertility. Surgical repair of varicocele
has been relatively successful in increasing sperm count but not fertility rates. Microsurgery to
reanastomose (restore tubal continuity) the sperm ducts after vasectomy can restore fertility.

Assisted Reproductive Therapies

The Centers for Disease Control and Prevention (CDC) (2012) defines assisted reproductive technology
(ART) as fertility treatments in which both eggs and sperm are handled. In general these treatments
involve removing the eggs from the woman, fertilizing the eggs in the laboratory, and returning the
embryo or embryos to the woman or surrogate carrier.

Some of the ARTs for treatment of infertility include in vitro fertilization–embryo transfer (IVF-ET),
gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), ovum transfer (oocyte
donation), embryo adoption, embryo hosting and surrogate motherhood, therapeutic donor insemination
(TDI), intracytoplasmic sperm injection (ICSI), assisted embryo hatching, and preimplantation genetic
diagnosis (PGD).