S.

N TIME SPECIFIC CONTENT TEACHING AV AIDS EVALUATION

O OBJECTIVES LEARNING
1 30 sec To establish Introduction about self
rapport among My name is Ms. Simranpreet kaur, assistant
the students professor in APS nursing collage, Malsian,
Jalandhar

2 1 min To access the Introduction:According to WHO, positive Teacher is Lecture

previous reproductive health of a woman is a state of introducing cum
knowledge of complete physical , mental & social well being the topic and discussion
group. & not merely absence of disease related to students are
reproductive system & function . It’s a serious listen
medical concern that affects quality of life & is a carefully
problem for a 10-15 % of reproductive age
couples.

3 1 min To define • Definition: Infertility is defined as Teacher is Lecture Define infertility

infertility the inability to conceive after one year defining the cum
of regular sexual attempt without topic and discussion
contraception when the couple gets students are PPT.
worried for a baby. listen
carefully
• Study based on an observation shows
that,
 80 % of normal couple conceive
within a year
 50 % of them within 3 months
 75 % of them within 6 months
4 30 sec To describe CLINICAL GROUPS OF INFERTILE Teacher is Lecture Describe
incidence rate COUPLE AS PER ETIOLOGY: telling the cum incidence rate
of infertility • Male defect in 40% clinical discussion of infertility
• Female defect in 50% groups of PPT
• Unexplained cause in 10% infertile
couple as per
etiology
5 2 min To enlist the TYPES OF INFERTILITY: Teacher is Lecture What are the
types of explaining cum types of
infertility PrimaryInfertility types of and discussion infertility
Secondary Infertility students are PPT
listen
• Primary infertility: It applies to those carefully
who have never conceived inspite of
bring in a regular relationship with
partner/spouse.

• Secondary infertility: It refers to the

case where conception has failed to occur
after a period of fertility.

• STERILITY:it’s an absolute state of

inability to conceive

6 3 min To Explain the FACTORS RESPONSIBLE FOR Teacher is Lecture What are the
factors INFERTILITY: explaining cum factors
responsible for the discussion responsible for
infertility • Healthy spermatozoa should be deposited responsible PPT infertility
high in vagina. factors for
• Motile sperm ascend through the cervix infertility
into uterine cavity and fallopian tubes.
• There should be ovulation.
 • The fallopian tubes should be patent and
oocyte should be picked up by fimbriated
end of the tube.
• Sperm should be picked up by fimbriated
end of the tube.
• Sperm should fertilize oocyte at the
ampulla of tube.
• Embryo should reach the uterine cavity
after 3-4 days of fertilization.
• Endometrium should be prepared for
implantation.

7 15 min To Explain CAUSES OF INFERTILITY: Teacher is Lecture Explain

Causes of describing cum Causes of
infertility • Depends on both partners fertility the causes of discussion Infertility
potential, male account for 30- infertility PPT
40%,female account for 40-50% of the
cases and 10% cases in which both
partners are responsible.
• Causes in female
• Causes in male
• Combined factors
CAUSES IN FEMALE:
1. Dyspareunia and vaginal causes
2. Congenital defects in the genital tract
3. Infection in the lower genital tract
4. Cervical factors
5. Uterine factors
6. Tubal factors
 7. Ovaries
* Anovulation
* Luteal phase defect
8. Peritoneal causes
9. Chronic ill health

1. Dyspareunia:important organic causes

are-
• Rigid or imperforate hymen
• Congenital stenosis
• Acquired stenosis
• Traumatic stenosis
• Prolapsed ovaries associated with
retroversion
2. Congenital defects in the genital tract:
• Absent or septate vagina
• Hypoplasia or absent uterus
3. Infection in the vagina and cervix :
Although mild infection may not prevent
sperms fast getting into the cervical
canal, it is prudent to clear the infection
before any therapeutic measures are
applied.
4. Cervical factors (5%) :
• Elongation of cervix
• Uterine prolapse
• Polyp in cervical canal

5. Uterine causes(10%) :
 Uterine hypoplasia
 Inadequate secretory endometrium
 Fibroid uterus
 Endometritis
 Congenital malformation of uterus

6. Tubal factors(25-30 %) :
 Defective ovum picked up.
 Impaired tubal motility.
 Loss of cilia.
 Partial or complete obstruction of tubal
lumen.
Fimbrial end blockage

7. Ovaries :
a) Anovulation or oligoovulation:

 No ovulation, no corpus luteum, no

secretory endometrium, absence of
progestrone.

b) Inadequate growth and functioning

of corpus luteum.

 Inadequate progestron secretion.

 Life span of corpus luteum is < 10 days
or there is insufficient progestron
secretion of progestron.
 As a result, there are less secretory
changes in the endometrium which
hinder implantation.

8. Peritoneal causes :

 Peritubal adhesions by kinking the

fallopian tubes cause blockage of the
tubes.
  These adhesions form part and parcel of
pelvic inflammatory disease.
 Impair the peristaltic movements of the
fallopian tubes.
 In pelvic endometriosis, macrophages in
the peritoneal fluid may engulf the ovum
and sperms preventing fertilization.

9. Chronic ill health :

 Hypothalamic disease
 Pituitary disease
 Hypothyroidism
 Adrenal cortical insufficiency.

8 8 min To describe the PATHOPHYSIOLOGY IN FEMALES: Teacher is Lecture Describe the

Pathophysiology  Hypothalamus dysfunction explaining cum Pathophysiology
In females the patho discussion In females
Ant. Pituitary Physiology in PPT
1 female of
infertility
Dec.gonadotropinsinc. prolactin

Ovaries

Abnormal levels of FSH, LH,

estrogen, progesterone
  Anatomical defects

Obstruction in movement of ova

No fertilization

Infertility

Anovulation & menstrualproblems

CAUSES IN MALE:
1. Defective spermatogenesis
2. Obstruction in efferent duct
3. Failure to deposit sperm high in vagina
4. Defect in sperm and sperm morphology

1. Defective spermatogenesis :
• Undescended testis
• Genetic
• Testicular toxins
- drugs
- radiation
• Endocrinal
- thyroid dysfunction
- GnRh deficiency
• Primary testicular failure
- varicocele
- cryptotorchism
- immunological
- orchitis
2. Obstruction in efferent duct:
a) Congenital
* absence of vas deferens
 b) Acquired
* Infection ( tuberculosis, gonorrhea)
* surgical trauma (vasectomy)

3.Failure to deposit sperm high in vagina

• Impotency
• Hypospadias
• Ejaculatory failure
• Drug related

4. Defect in sperm and seminal fluid:

• Immotile sperm
• Sperm antibodies
• Undue viscosity

9 7 min To explain Teacher is Lecture Explain

pathophysiology PATHOPHYSIOLOGY IN MALES explaining cum pathophysiology
in males and the patho discussion in males and
combined Inc. scrotal temp physiology in PPT combined
factors of male of factors of
infertility infertility infertility
Germ cells damage

Infertility

• Bacterial & viral infections

Bioactive cytokines
 Inflammation

Inc. scrotal temp

Germ cell damage

Infertility

COMBINED FACTORS:
• Advanced age of wife beyond 35 years.
• Infrequent coitus due to lack of
knowledge of coitus, technique and
timing of coitus ( to utilize fertile period).
• Anxiety and apprehension.
• Use of lubricants which may be
spermicidal.
• Obesity - coitus difficulty
smoking – defective spermatogenesis due to
nicotine
alcohol - paired sexual function
diabetes- impotency

• Excessive use of drugs like

 antiepileptic
 antipsychotic
 antihypertensive
 cimetidine
 chemotherapy
 nitrofurantoin
 beta-blockers
  spirolactone
 estrogen
 excessive use of testosterone and
anabolic steroid by athletes.

SECONDARY INFERTILITY:

FEMALES :
• Uterine synaechiae
• Endometrial tuberculosis
• Pelvic endometriosis
• Vaginal stenosis
• Cervical stenosis
• Post MTP cornual block
tubectomy

MALES :
• Vasectomy
( obstructive azoospermia

10 15 min To describe the Assessment: Teacher is Lecture Describe the

diagnostic test • History of Describe the cum diagnostic test
for infertility diagnostic for infertility
 age discussion
test for
 occupation PPT
infertility
 educational background
 Duration of infertility
 past obstetrical
 menstrual cycle
 coital history
 Medical and surgical
 sexually transmitted diseases
* Frequent episodes of fever of any cause can
suppress spermatogenesis for as long as 6
months.

PHYSICAL EXAMINATION:
• In malesit could be postponed until after
the semen analysis.
• However , general height, weight,
obesity, secondary sex characters, thyroid
enlargement should be looked for.
• In females, height & weight of the
woman, blood pressure should be
checked.
• Abnormal uterus and tubes (exposure to
DES) via bimanual examination should
be looked for.

Tests for tubal patency:

• A mere patency of the tubal lumen is not

the only criteria to effect fertility. The
normal physiological functions of the
fallopian tube is essential for pregnancy
to occur. The endosalpinx is lined by
ciliated epithelial cells & the secretory
cells. The cilia help in propulsion of the
fertilized egg towards the uterine cavity.
The secretory cells provide nutrition to
the sperms as well as the ovum during the
passage across the tube.Theperistaltic
movements of the fallopian tube are
under the influence of oestrogen,
progesterone and prostaglandins and
 synchronized movements help in the
propulsion of sperms and fertilized egg in
the either direction. The ovarian fimbriae
are spread over the ovary at ovulation
and bring the ovum into the fimbrial end.

Hysterosalpingography:

• It’s the visualization of the uterine cavity

and the fallopian tubes carried out by
screening with the use of an image
intensifier in an x-ray room using a foley
catheter with 15 ml of the radiopaque dye
injected into the uterine cavity.
• complications: 1) pelvic infection
2) pain & collapse
3) allergic reaction

Laparoscopic chromotubation:

• It’s the laparoscopic visualization of the

pelvis, fallopian tubes and ovaries and
injection of methylene blue through the
cervix.
• Used when hysterosalpinography has
shown blocked tubes.
• Its an invasive procedure & needs
hospitalization.

Sonosalpingography:
 • Also called as the “Sion test”
• In this test, under ultrasound scanning , a
slow and deliberate inj. of about 200 ml
of saline into the uterine cavity is
accomplished via Foley catheter, the
inflated bulb of which lies above the
internal os and prevents leakage.
Its possible to visualize the flow of saline along
the tube , and observe it issuing out as shower at
the fimbrial end.

Newer modalities:

1. Hysteroscopy : The interstitial end of the

fallopian tube can be visualized. Cornual
polyp is detected in 10 % cases and their
biopsy can be taken.
2. Transcervicalfalloscopy : It visualizes the
lumen of the tubes. Hysteroscopic tubal
cannulation at the medial end can be
therapeutic if the blockage is due to
mucus plug or mild flimsy adhesions.
3. Ampullary and fimbrialsalpingoscopy : It
is used to study the mucosa of the
fallopian tube in deciding between tubal
microsurgery and in-vitro fertilization.
Descending test using starch is injected
into the pouch of Douglas. The presence
of starch in cervical mucus 24 hours later
indicates patency of one or both tubes.
11 10 min To enumerate Management of Tubal infertility: Teacher is Lecture Enumerate
management of Enumerating cum management of
infertility management discussion infertility
1. Tubal microsurgery :It is advocated of infertility PPT
in tubal blockage. It has various names
depending upon the site of blockage. The
risks of tuboplasty are:
* anaesthetic complications
* postoperative wound & chest infection
* embolism
* failure
* ectopic pregnancy
2. Laparoscopic tubal adhesiolysis,
fimbrioplasty& tubal surgery have
yielded good results.
3. In-vitro fertilization: It is offered to
women in whom tuboplasty has failed or
to women with extensive &irreparable
tubal damage. Contraindications to it are
extensive pelvic adhesions & inaccessible
ovaries due to adhesions, ova retrieval in
such cases may be impossible
4. Tubal reanastomosis typically is used to
reverse a tubal ligation or to repair a
portion of the fallopian tube damaged by
disease. The blocked or diseased portion
of the tube is removed, and the two
healthy ends of the tube are then joined.
This procedure usually is done through
an abdominal incision ( laparotomy ).
5. Salpingectomy, or removal of part of a
fallopian tube, is done to improve in vitro
fertilization (IVF) success when a tube
has developed a buildup of fluid (
hydrosalpinx ). Hydrosalpinx makes it
 half as likely that an IVF procedure will
succeed.
6. Salpingostomy is done when the end of
the fallopian tube is blocked by a buildup
of fluid (hydrosalpinx). This procedure
creates a new opening in the part of the
tube closest to the ovary. However, it is
common for scar tissue to regrow after a
salpingostomy, reblocking the tube.
7. Fimbrioplasty may be done when the part
of the tube closest to the ovary is partially
blocked or has scar tissue, preventing
normal egg pickup. This procedure
rebuilds the fringed ends of the fallopian
tube.

Care After Surgery:

• After open abdominal surgery, there

usually is a 2- to 3-day hospital stay.
Antibiotics may be given to prevent
infection. A woman usually can return to
work in 4 to 6 weeks, depending on the
extent of surgery, the nature of her work,
and her overall health and stamina.
• After laparoscopic surgery, there is a
brief hospital stay. A woman's return to
daily activities can take a few days to a
couple of weeks, depending on the type
of procedure.

8. Ballontuboplasty&cannulation is done
through transcervical route for medial
 end block.
9. Tubal cannulation
10. Gamete intrafallopian transfer (GIFT): In
this, the ovum with the sperms are placed
in the distal end of the fallopian tubes at
ovulation under guidance of the
laproscope

11 5 min To explain tests Tests of ovulation: Teacher is Lecture Explain tests of

of ovulation and Basal body temperature: It is established that Explaining cum ovulation and its
its management tests of discussion management
BBT falls at the time of ovulation by about ½
ovulation and PPT
degree Fahrenheit. Subsequently during the its
progestational half of the cycle the temperature management
is slightly raised above the preovulatory level.
This is due to the thermogenic action of
progesterone & is hence presumptive evidence of
the presence of a functioning corpus luteum &
hence ovulation.
2. Endometrial biopsy : It consists of
curetting small pieces of the
endometrium from the uterus with a
small endometrial biopsy curette,
preferably 1-2 days prior the onset of
menstruation.
• The material should be fixed immediately
in formaline saline & histologically
examined..
• It is subjected to guinea pig inoculation
& culture to rule out genital tuberculosis.
3. Fern test : A specimen of cervical mucus
obtained by platinum loop is spread on a
glass slide & allowed to dry.
• Microscopic examination shows a
 characteristic pattern of fern formation
( estrogenic phase).
• This ferning disappears after ovulation.
This ferning is due to the presence of
sodium chloride in the mucus secreted
under estrogen effect.
• At the time of ovulation, the cervical
mucus is thin & profuse that the patient
may notice a clear discharge , the so
called normal ovulation cascade.
• Spinnbarkeit or thread test : The
ovulation mucus has the property of great
elasticity & can withstand stretching upto
10 cm (estrogen activity)
• Tack : during the secretory phase, the
cervical mucus becomes tenacious & its
viscosity increases so that it loses the
property of spinnbarkeit& fractures when
put under tension.This property is called
tack.

TREATMENT DRUGS:
• Plasma progesterone : a low conc. of it
needs,
♦ Administration of hCG 5000-10,000 IU
weekly
♦ Micronized progesterone (oral) 100mg
b.i.d or 300 mg vaginal pessary twice
daily.
♦ Weekly Prolution inj. 500mg
• Hyperprolactinaemia(> 25 ng/ml) :
responds well to 1.25 mg bromocriptine
at bedtime O.d for 7 days.
Drugs to manage Anovulation:

☻ Clomiphine citrate {CC} : ovulation

should be induced with it, with a dose of
50 mg/day to 100 mg/day starting from
day 2 to day 6 of the cycle.
☻ Combination of cc &hMG: in polycystic
ovarian disease, ovulation is ideally
induced with a combination of cc
&hMG( human menopausal
gonadotropin ) .
☻ Use clomiphine citrate 50-100mg/day
from day 2 to day 6 of the cycle. Inj.
hMG 75 units I/M on day 3, 5 & 7 &
more if so required.
☻ Prednisolone : 5mg at night & 2.5 mg
every morning till spontaneous ovulation
sets in.

Semen analysis:
• The basic test to evaluate a man’s fertility
is a semen analysis. To perform this test,
a man collects a sample of his semen in a
collection jar during masturbation either
at home or at the physician’s office.
• A man should abstain from ejaculation
for several days before the test, because
each ejaculation can reduce the number
of sperm by as much as a third. (The
maximum number of sperm is usually
obtained by abstaining for about four
days.)
• Proper collection procedure is important,
since the highest concentration of sperm
is contained in the initial portion of the
ejaculate. The sample should be kept at
body temperature and delivered
promptly, because if the sperm are not
analyzed within two hours or kept
reasonably warm, a large proportion may
die or lose motility.
• A semen analysis should be repeated at
least three times over several months..
• The analysis should report any
abnormalities in sperm count, motility,
and morphology as well as any problem
in the semen.
• Total volume: 3-5 ml ( average 3.5 ml),
viscous
• Sperm count: 60-120 million/ml (average
100 million )
• Motility: 80-90 % (average 80%)
• Morphology: 80% or more normal (
average 80% )
• pH: 8
Ώ Pus cells should be absent.
Ώ Seminal fluid normally contains fructose.
Ώ Aspermia – means no sperm
Ώ Azoospermia- implies no sperm is seen.
Ώ Asthenospermia – no motile sperm or
dimnished motility.
Ώ Necrospermia- dead sperms
Ώ Teratospermia- abnormal morphology of
sperms
 Ώ Counts below 20 million/ml are usually
associated with infertility.

Postcoital test:
• The postcoital, also known as Simms–
Huhner test is designed to evaluate the
effect of a woman’s cervical mucus on a
man’s sperm.
• To perform this test, a woman is asked to
come into the physician’s office within
two to 24 hours after intercourse at mid–
cycle (when ovulation should occur).
• A small sample of cervical mucus is
obtained and examined under a
microscope. A problem is detected if the
physician observes no surviving sperm or
no sperm at all.

• If results are poor, the woman’s cervical

mucus should also be cultured for the
presence of infection.
• The test can indicate that a problem
exists but cannot determine its cause in
most cases. The test also cannot evaluate
sperm movement from the cervix into the
fallopian tubes or the sperm’s ability to
fertilize an egg.Penetration less than 3 cm
at 30 min. is abnormal.

Antisperm Antibodies Test:

• If a man has had a vasectomy reversed

and still cannot conceive or if semen
 analysis shows sperm clumping together,
blood tests for anti–sperm antibodies will
be conducted. The primary negative
effect of these antibodies is to bind the
sperm to the woman’s cervical mucus,
preventing the sperm from swimming
further. up.
• The best method available today is one
such uses immunobeads, which allow
determination of the location of the
antibodies on the sperm surface. If they
are present on the sperm head they can
interfere with the sperm’s ability to
penetrate the egg; if they are present on
the tail they can retard sperm motility

Sperm penetration test:

• Since the basic function of a sperm is to

fertilize an egg, scientists were very
excited when they found that normal
sperm could penetrate a denuded (zona-
free) hamster egg.
• A zona-free hamster egg is obtained from
hamsters and the covering (the zone)
removed by using special chemicals. The
egg are then incubated with the sperm in
an incubator in the laboratory.
• After 24 hours, the eggs are checked to
ascertain how many sperm have been
able to penetrate the egg. The result gives
a penetration score, which gives an index
of the sperm’s fertilizing potential. This
 is a very delicate technique and is not
available in India.

Semen-cervical mucus contact test:

• Equal quantity of semen & mucus is

mixed, so there is no interface. In
presence of antibodies more than 25%
sperms show jerky or shaky movements
by 30 min. The cross check with the
donor semen will indicate the source of
antibodies, whether it is cervical or
seminal antibodies

Testicular Biopsy:

• Occasionally, a testicle biopsy may be

performed in which tissue samples are
removed under anesthesia.
• A biopsy is most useful for detecting
obstruction in the transport system when
sperm production looks normal but the
count is low.
• The standard biopsy procedure requires
incisions (called an open approach) and
can be painful afterward.
• The procedure is valuable not only for
diagnosis of infertility and predicting
fertility treatment success, can be used to
retrieve sperm for fertility procedures
too.
 Chromosomal study:

• Karyotyping should be undertaken in

cases of azoospermic men, as 15- 20% of
them have chromosomal disorders. The
most common is KLINEFELTER’S
SYNDROME with 47 XXY karyotype.

• Ultrasound : Ultrasound scanning of the

scrotum detects scrotal volume,
hydrocele.
• Vasogram : It is required when normal
FSH level is associated with azoospermia
• Urinalysis : In suspected retrograde
ejaculation, urine is made alkaline before
collection & centrifuged . The presence
of sperms in the urine proves retrograde
ejaculation.

12 10 min To explain Management of male infertility: Teacher is Lecture cum Explain

management of Explaining discussion management of
Male infertility • Antibiotics like Doxycycline 100mg b.i.d manageme PPT Male infertility
for 6 weeks to treat infection. nt of
Male
• Hormones like testosterone, pituitary
infertility
hormones &GnRH to improve
spermatogenesis.
Bromocriptine is useful in hyperprolactinaemia

• HCG : 10,000 IU I/M weekly for 10

weeks improves testosterone secretion, &
pregnancy rate by 38 %. Alternatively
5000 IU may be given twice a week.
 • Testosterone : 25-50 mg daily (orally)
improves testicular function. A larger
dose of 100-150 mg daily suppresses
spermatogenesis.
• Clomiphine : 25 mg daily for 25 days
followed by rest for 5 days is given
cyclically for 3-6 cycles in hypogonadal
infertility.
• hMG : 150 IU thrice a week for 6 months
is recommended in pituitary inadequacy.
• Tamoxifen : 10 mg daily for 6 months.
• Dexamethasone : 0.5 mg daily or 50 mg
Prednisone daily for 10 days each for 3-6
months to treat spermalantibodies.
• Sidenafil (viagra) : 25-100 mg one hr
before coitus improves erectile function.
But recent reports on cardiac ischemic
heart disease is alarming, along with
color visual disturbances & headache
have also been reported. Its
contraindicated in men on hypotensive
drugs.
• Artificial insemination : The donor for
insemination is screened for HIV, STD &
hepatitis B & a good quality of semen
confirmed.
Management of Azoospermia:

• With oligospermia or abnormal semen,

the couple may be offered:
∞ In-vitro fertilization (IVF)
∞ Gamete Intrafallopian Transfer (GIFT)
∞ Micro-Assisted Fertilization technique
 (MAF)
∞ Microsurgical Epididymal Sperm
Aspiration (MESA) or Percutaneous
Epididymal Sperm Aspiration (PESA)

13 3 min Teacher is Summary: Teacher is Lecture cum

summarize the summariz discussion
topic • Definition of infertility ation of PPT
• Incidence of infertility the topic
• Etiology of infertility (in males and
females)
• Diagnostic tests for infertility (males and
females)
• Management of infertility (males and
females)

14 2 min To recapitualize Recapualization:

the topic
• Define infertility
• What are the incidence rate of infertility
• Explain etiology of infertility
• Describe diagnostic tests for infertility
• Explain Management of infertility
15 1 min Bibliography:
 Brunner &suddarth. text book of medical
surgical nursing (10th): 1400-03.
 Black Joyce M,Hawks Jane Hokanson
.Medical Surgical Nursing 2009;
1(8th):866-904.
 Phipps , sands & Marek. Text book of
medical surgical nursing;(6th):1529-70.
 SELF IDENTITIFICATION DATA

Subject: Medical Surgical Nursing

Topic: Infertility

Name: Simranpreet Kaur

Type of teaching lecture cum discussion

Group B.SC 3rd year

Place Classroom

Av aids Power point presentation, black board

General objective: At the end of teaching the group will be able to understand about Infertility

Specific Objectives: At the end of discussion the students will be able to –

• Define infertility
• Enumerate the incidence rate of infertility
• Explain etiology of infertility
• Describe diagnostic tests for infertility
• Explain Management of infertility
 LESSON PLAN ON
INFERTILITY

SUBMITTED BY SUBMITTED BY
RESPECTED Simranpreet kaur
MRS, Dr Sharad Chand Gupta Assistant Professor
Principal college of nursing APS College of Nursing, Malsian