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Infertility
MDWF 2100
Katlyn Carter
July 23, 2019
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Infertility

Background

Infertility is defined as “failure to conceive after 1 year of regular, unprotected

intercourse (Smith, 2018, Weschler, 2015)”. Infertility affects 6-12% of the American population

(Smith, 2018). Under ordinary circumstances, 80-90% of couples conceive during one year of

attempting pregnancy (Smith, 2018). Infertility may be subdivided further into 2 categories,

primary and secondary, based on the client’s past reproductive history:

 Primary: clients with infertility who are nulligravid (slightly more than half of infertility

clients fall into this group)

 Secondary: those who have achieved a pregnancy more than 1 year previously, regardless

of the outcome of that pregnancy (Smith, 2018) or those who cannot sustain a pregnancy

(Davidson, et al., 2016).

 Note: the term “subfertility” is used to describe a couple having difficulty conceiving

because both partners have reduced fertility (Davidson, et al., 2016), and could be

primary or secondary

With further understanding of the physiology of conception and the range of technologies

available, 85% of couples may be helped (Smith, 2018).

Infertility also has a profound emotional, psychological, and economic impact on the

affected couple.

Etiology

To achieve pregnancy, there are 3 critical elements that must be in place:

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 A sperm must be available

 An egg must be available

 The sperm and egg must meet at a time and place conducive to fertilization (Smith, 2018)

While this seems very simple and elementary, all considerations regarding finding causation and

treating it revolve around these three elements.

Many factors affect male and female infertility, including both genetic and environmental

factors. Environmental factors include obesity, sexually transmitted infections, stress, caffeine or

alcohol consumption, use of herbal remedies, and exposure to cigarette smoke and toxic

chemicals (Davidson, et al., 2016).

Certain lifestyles can impact fertility. Cigarette smoking in females can delay time of

conception and increase the risk for spontaneous abortion, preterm labor, and low birth weight

(Davidson, et al., 2016). In men, smoking can impact the quality and quantity of sperm

(Davidson, et al., 2016). Alcohol and caffeine consumption have been associated with

subfertility (Davidson, et al., 2016). Weight and body mass index are associated with

anovulation and oligomenorrhea in females, and poor spermatogenesis and increased amount of

time to conception in men (Davidson, et al., 2016). After completing a thorough medical history,

other factors may surface that can affect fertility: cancer treatment, STIs, personal habits, etc.

Occupational and environmental exposures to chemicals have been associate with male

fertility including benzene, BPA, phthalates, and pesticides may interfere with endocrine

signaling and increase the rate of infertility (Davidson, et al., 2016).

Conventional Therapy
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Conventional therapies for a female should include a complete physical exam, pelvic

exam (including PAP and STI testing), bimanual examination, rectovaginal exam, and complete

labs (Davidson, et al., 2016). Conventional therapies for a male should include a complete

physical exam, urologic exam, rectal exam, and complete labs (Davidson, et al., 2016). The

results of these interviews and evaluations determine what will come next.

Figure 1(Davidson, et al., 2016, p. 197)

The conventional therapy used will vary greatly among clients because each individual or

couple will have very individualized needs. The details of all the options are too extensive to

delve into for the purpose of this paper.

Alternative Therapy
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Some couples that are experiencing infertility may seek alternative therapies that may

include pelvic physical therapy, hypnosis, homeopathy, spiritual healing, acupuncture, and

herbal therapy (Davidson, et al., 2016). The two most common alternative used are acupuncture

and herbal treatments.

Acupuncture is a therapy used in traditional Chinese medicine and involves inserting

sterile needles into specific points on the body to control the flow of chi (life energy). As the chi

is balanced in the kidneys and adrenal glands, it has been shown to be effective by inhibiting

uterine motility during embryo transfer and improving the endometrial environment for embryo

implantation (Nandi, et al., 2014). Several studies have shown that acupuncture can increase the

clinical pregnancy rate and live birth rate among women undergoing IVF (Davidson, et al.,

2016).

Herbs commonly recommended to treat infertility include ginseng and astragalus both

known for having healing and hormone-balancing effects. In Traditional Chinese Medicine,

ginseng has also been used to enhance male virility and fertility (Davidson, et al., 2016). There

are many fertility enhancing herbs available.

Counseling & Education

Counseling for couples who have or are experiencing infertility can be extremely

beneficial. For many couples, the feeling of being infertile does not instantly disappear once they

become pregnant. Once pregnant, the parent(s) is no longer in contact with the fertility

specialists they had been working with and may experience feelings of isolation as they navigate

finding a new, “normal” care provider (Davidson, et al., 2016). Another possibility with assisted

reproductive technologies is the higher probability of multiple gestations. About 20% of twins
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are conceived naturally, 39-67% are related to ovulation induction, and 13-44% are associated

with assisted reproductive technologies, such as IVF (Davidson, et al., 2016). Multiple gestations

are also at a significantly higher risk of fetal, neonatal, and maternal complications. These

parent(s) could greatly be supported by counseling and continued education as their journey

continues.

In addition, the economic stress is a concern as treatments can be costly and often

insurance coverage is limited. A couple may experience years of effort, multiple evaluations, and

many cycles of psychological stress.

Infertile couples may face marital tension as care providers are intruding (albeit

necessarily) on their sex life and dictating when and how things should happen. Evaluations,

tests, treatments, etc. may leave a couple with feelings of anger, frustration, disappointment,

guilt, or shame (Davidson, et al., 2016).

It is important to be aware of the emotional needs of the couple undergoing reproductive

assistance. It is important to recognize the multidimensional needs of the “individual or couple

within physical, social, psychologic, spiritual, and environmental contexts (Davidson, et al.,

2016, p. 209).” The midwife can act as a counselor, educator, and advocate. A midwife may also

refer to mental health professionals when an individual or couple’s life becomes too disrupted. In

addition, individual or group counseling with other infertile couples can help the couple resolve

feelings brought about by their own difficult situation (Davidson, et al., 2016).

Midwives Model of Care

The Midwives Model of Care can greatly benefit those struggling with fertility.

Midwives can provide clients with the individualized education and counseling to walk with
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families on their journey of fertility. While technological interventions may be necessary,

midwives can provide options of complementary and alternative services that can ease the

process for clients. Knowledgeable midwives may be able to help facilitate clients understanding

and awareness of their cycles which can help couples know when to time intercourse so it better

coincides with ovulation, thus increasing the likelihood of pregnancy. Regardless of the

outcome, knowledge of one’s body can be empowering and provide excellent information to

referring providers. Furthered information can help the couple establish the relevant cause(s) of

infertility. Midwives can also aid clients in seeking counseling and social networking that can

help with the psychological and social needs of a couple trying to conceive.

In addition, midwives may be aware and respectful of clients’ unique, cultural needs.

While culture is very individualized, it may be helpful to understand the acceptance of infertility

treatments varies widely around the world. Some belief systems do not allow certain treatments

but are open to others. For example, artificial reproductive technology in predominantly Muslim

countries is not only accepted, but encouraged, because adoption is not an acceptable solution

(Davidson, et al., 2016). However, the approved methods are limited because the use of donor

sperm or eggs is prohibited (Davidson, et al., 2016). In Jewish cultures, it is acceptable to use

artificial reproductive technology, including egg and sperm donation, however, Jewish law

prohibits women from engaging in sexual intercourse from the start of their menstruation until 7

days after the end of mensus, perhaps making it difficult for those who spot or have

irregular/unpredictable cycles to conceive (Davidson, et al., 2016).

I believe that midwives and the Midwives Model of Care can greatly benefit couples

trying to conceive and those may be experiencing infertility. While, in the state of Washington, it

is not within the scope of practice of CPMs to offer well person care, we can offer preconception
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counseling. Sitting with an individual or couple trying to conceive, listening to their story, and

counseling, educating, and referring is what we are good at. Education surrounding tracking

cycles, confirming ovulation, etc. and the knowledge of complementary and alternative therapies

can help couples get started on the right track and feel supported.
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References
Davidson, M., London, M., & Ladewig, P. (2016). Olds’ maternal-newborn nursing & women’s
health across the lifespan. Boston: Pearson.

Frye, A. (2013). Holistic midwifery volume I: a comprehensive textbook for midwives in

homebirth practice: caring during pregnancy. Labrys Press.

King, T. L., Brucker, M. C., Kriebs, J. M., & Fahey, J. O., Gegor, C. L., Varney, H.
(2015). Varney's midwifery. Jones & Bartlett Learning.

Nandi, A., Shah, A., Gudi, A., & Homburg, R. (2014). Acupuncture in IVF: A review of current
literature. Journal of Obstetrics and Gynaecology, 34(7), 555-561.

Smith, R. P. (2018). Netter's obstetrics and gynecology. Elsevier Health Sciences.

Weschler, T. (2015). Taking charge of your fertility: the definitive guide to natural birth control,
pregnancy achievement, and reproductive health. HarperCollins Publishers.

RUBRIC

Total Points Available

Etiology & Background Information 25 points
Conventional and Alternative Therapies 15 points
Counseling and Education 25 points
Discussion of the Midwifery Model of Care as it relates to topic 25 points
Use of appropriate APA style and citing format 10 points