NU 124

INTIMACY VS ISOLATION

Taking a Sexual History

5Ps: partners, practices, protection, past Hx, prevention

Explain purpose of interview

Ask open-ended questions
Clarify terminology
Go from easier to more difficult topics
Be alert to body language
Listen and be non-judgmental (be culturally aware)
Use teachable moments to educate
Document all RX and OTC meds, alcohol and drug use
Hx of past/present illness &/or surgeries that can affect fertility

INFERTILITY

What is infertility? Inability to conceive after 1 year of unprotected intercourse.

(6 months for older people around 35)

• primary infertility- couple who has never conceived

• secondary infertility- couple who have been pregnant but have a problem later

• subfertility- problem where both partners have decreased fertility

What factors influence fertility: also have issues related to weight, stress, STIs,
smoking, alcohol, age, health/chronic disease, meds/drugs, environmental hazards,
pesticides.

male factors-sperm, genital tract, ejaculation, etc.

female factors- favorable cervical mucus, patent tubes, ovulation, adequate

hormones

Causes of Male Infertility

Low sperm count or anitbodies to own sperm

Chronic infection
Increased scrotal heat— type of underwear, sitting all day, frequent hot tub or
sauna use
Heavy use of alcohol or drugs can decrease sperm count
Testicular inflammation and scarring from surgery, injury, etc
 Increased age can cause decreased quality of sperm
Obstruction of sperm motility from possibly infections, prostate enlargement
Difficulty with ejaculation--- the elder, diabetic, etc.
Exposure to lead and pesticides can decrease sperm count
STIs
Too frequent of intercourse will not allow sperm count to replenish as well

Essential components of fertility: male

• normal semen analysis. Semen analysis one of best initial tests: noninvasive,
inexpensive, quick. Is single most important test for the male partner.

• To obtain a specimen: no intercourse for 2-3 days before collection, best with
masturbation due to pre-ejaculate contains sperm as well. Obtained in a sterile
specimen cup and taken to lab within 1 hour after collection, must be kept warm
on way to lab. The test may need to be repeated.

• Normal values of a semen analysis:

• volume 2-5 ml
• pH 7.0-8.0
• total sperm count >20 million
• motility 50% or greater
• normal form (shape) >30%

• unobstructed genital tract- trauma, a vasectomy, tumors are issues that can cause
obstructions to the flow of sperm from the genital tract

• normal genital tract secretions needed to help with movement of the sperm

• ejaculated sperm deposited at cervix: premature ejaculation, impotence, obesity

(not adequate penetration), spadias can cause issues with this

Essential components of fertility: female

• favorable cervical mucus. Antisperm antibodies can cause sperm to be killed off
in genital tract

• clear passage between cervix and tubes. Adhesion and endometriosis are two
issues that can cause problems

• patent tubes with normal motility: PID, hx of tubal ligation, STIs, endometriosis
can cause motility problems
 • ovulation and release of ova: PCOs and lactation can be issues with ovulation

• no obstruction between ovary and tubes: adhesions, PID and endometriosis can
cause issues here

• adequate reproductive hormones that will be able to support a pregnancy after

implantation into the uterine endometrium

Female Infertility—each will be discussed after this list

1. Ovulatory disorder
2. tubal
3. uterine
4. cervical
5. benign lesions/endometriosis

Ovulatory Disorder

Anovulation: faulty of inadequate production of ova. Causes can be PCOS,

decreased or increased weight, poor diet, tumors, etc.

Evaluation of Ovulatory Factors in relation to infertility:

(italics information is regarding hormonal function in reproduction)

Basal Body Temperature (BBT)

Helps identify follicular, ovulatory and luteal phase abnormalities. Nurses

responsibility to teach the woman how to record the BBT accurately. Must begin a new
chart on the first day of every monthly cycle. Need a thermometer that is marked in
tenths….so can see small changes in temp. temperature is recorded daily; good time is
before getting out of bed. Really need several months of recordings to get a good picture
of what occurs. Helps detect ovulation and help with timing of intercourse. The BBT is
pre-ovulatory (follicular) phase is usually below 98. As ovulation approaches, the
production of estrogen increases and at its peak may cause a slight drop then rise in the
BBT. With ovulation, there is a surge of LH (luteinizing hormone) which stimulates the
production of progesterone, that will cause a 0.5 to 1 degree rise in temp for the 2nd half
of the menstrual cycle (luteal phase). Actual release of ovum likely occurs 24-36 hours
prior to 1st temp elevation…. temp rise doesn’t predict ovulation day but shows that
ovulation occurred about a day after it has occurred. If trying to conceive, HCP may
recommend intercourse every other day beginning 3-4 days before anticipated temp rise
until 2-3 days after anticipated day of ovulation.
 Gonadotropin levels (FSH, LH)

Should have baseline levels of these drawn for reference of ovulatory function.
Low levels may indicate hypothalamic/pituitary dysfunction and high levels can indicate ovarian
failure or poor ovarian function. FSH is great test to look at ovarian reserve and function. LH
levels may be drawn early in the cycle to rule out androgen excess disorders. LH may be drawn
daily at midcycle to detect a surge…..surge is believed to be the day of maximum fertility.
Ovulation is believed to occur 24-36 hours after the onset of the LH surge and 10-12 hours after
peak of LH surge.

FSH causes maturation of follicle, stimulates growth of ovarian follicle

LH causes release of mature follicle, main function is to cause ovulation

Steroid hormones (estrogen, progesterone)

Estrogen provides indirect measurement of oocyte development and maturation.

Causes endometrium to thicken before ovulation. Assists in maturation of follicle and causes
endometrial mucosa to proliferate following menstruation. Inhibits FSH and stimulates LH.
Estrogen levels fall 1 day before ovulation.

Progesterone provides best evidence of ovulation and corpus luteum function.

Serum levels begin to rise with LH surge and peak about 8 days later. A level of 3ng/ml 3 days
after LH surge generally means ovulation occurred. Causes endometrium to mature so can
support implantation. “hormone of pregnancy”. Allows pregnancy to be maintained. The rise
in temp (0.5 to 1) that accompanies ovulation is due to progesterone.

Prolactin

Increased levels are often cause of ovulatory dysfunction. (CNS meds can affect)

Androgen levels (testosterone)

Androgen excess can originate from the adrenal glands, ovaries or peripheral
tissues. Symptoms of excess: acne, facial hair, ovulatory dysfunction.

Ultrasound

Transvaginal ultrasound used for follicular monitoring of clients undergoing

ovulation induction cycles, for timing of ovulation for insemination, and intercourse, for IVF
oocyte retrieval, monitoring of early pregnancy.
 Endometrial biopsy

Used to assess the adequacy of the corpus luteum function and endometrial
receptivity. Useful for determining presence of ovulation. Often client will experience
cramping, pelvic discomfort, and spotting after the biopsy.

Polycystic Ovarian Syndrome (PCOS)

What is PCOS? It is an imbalance of hormones, major cause of medically

treatable infertilility. Have a change in cycles, skin changes, small cysts in ovaries
(follicles don’t mature) women with PCOS are at risk for chronic diseases such as
increased cholesterol, DM, cardiac disease, etc.
Symptoms of PCOS:
• menstrual dysfunction
• androgen excess
• obesity
• hyperinsulinemia
• infertility

Tubal and Uterine Disorder. tubal obstruction may occur because scarring and adhesions or
infections. Tubal patency tests are usually done after less invasive tests have been done.

Chronic salpingitis (inflammation of tubes)

stricture of fallopian tubes
uterine tumors
inadequate endometrium formation from decrease in hormone production
uterine scarring

Evaluation of uterine structures and tubal patency: ****we will look at and discuss
these in class****

• hysterosalpingography (HSG) or hysterography (put dye in uterus early in stage

before ovulation so you don’t potentially flush out pregnancy)

• hysteroscopy (done in office or can be done with laparoscopy under anesthesia;

looking for fibroids etc.)

• laparoscopy (under anesthesia; blow them up with carbon dioxide and puncture
their bellies; encourage movement after to pass gas)
 • transvaginal ultrasound (sonohysterography) (done in office by putting saline in
uterine cavity)

Cervical Problem

Infection of cervix may cause a change in cervical mucus so that sperm cannot penetrate
the follicle or cannot survive.

Evaluation of cervical factors:

- spinnbarkheit test (test cervical mucus and see its elasticity; excellent result is 8-10
cm stretched between two glass slides)
- fern test (take cervical mucus and let it air dry; they look for a fern pattern on that
slide right before ovulation)

- antisperm antibodies (????)

Endometriosis

Is when endometrial tissue grows outside of the uterus--on the ovaries, fallopian
tubes, ligaments that support the uterus, and other areas in the pelvic cavity. Can cause
issues with getting pregnant.
Most common symptom is pelvic pain; painful intercourse and abnormal uterine
bleeding are other symptoms.
May be given Danocrine to suppress ovulation and menstruation and to effect
atrophy of the ectopic endometrial tissue
Also may be given combined oral contraceptives, Lupron, or progestins to help
with endometriosis

Infertility Diagnosis—testing generally proceeds from simple and least cost and least
invasive to increased . always be aware of cultural aspects that can relate to dx and tx.

Medical and Sexual History of both partners

Lab tests of both partners

• Male: semen analysis

Female:
• ovarian assessment
• testing ovulation
• uterine and tubal assessment
• cervical assessment
Physiologic and Psychologic Effects of Infertility

Stress on marriage
guilt
frustration
anger
shame
loss of control
stress on marriage and sexual relationship
Depression
Grief
Helplessness

Emotions related to infertility—many couples are not prepared for the emotional roller coaster
that goes along with infertility dx, tx, and tests. ****we will further discuss this in class*****

Embarrassment
Threatened self-esteem
Anger
Jealousy
Blaming
***Can be a life crisis. Strains the couple emotionally, physically, and financially.

Couple must decide to commit to the process of treating the fertility problem

Treatment of Infertility

Pharmacologic

Assisted reproduction

Therapeutic insemination (THI or TDI)

IVF; GIFT; ZIFT or TET

IVF with donor oocytes

embryo cryopreservation

gestational carrier/surrogate carrier

adoption

Infertility Medications pg. 1278-1279 in Pharmacology book

 Clomiphine (Clomid)—1st line therapy to induce ovulation. Used with normal ovaries,
normal prolactin levels. Increases LH and FSH (stimulates the growth of follicles and
release of the ova). Usually 50-100 mg every day on cycle day 3-7 or 5-9—5 days of
meds. Usually advise intercourse every other day for 1 week starting 5 days after last
dose of meds. Side effects: hot flashes, N/V, H/A, mood swings, abdominal distention
and bloating. Can causes hyperstimulation of ovaies—will usually see abdominal pain.

Bromocriptine (Parlodel)—used for increased prolactin levels and anovulation because

allows FSH and LH production. D/C this at time of anticipated ovulation.

Metformin (Glucophage)—oral med to tx DM. used often with PCOS pts due to insulin
problems associated with this disorder.

Progesterone—for luteal phase support, it makes endometrium more receptive for

fertilized egg.

hCG (human chorionic gonadotropin)—given to stimulate natural LH surge, results in

ovulation at an expected time.

Gonadotropins—1st line with anovulatory pts with low to normal LH and FSH levels,
requires close monitoring due to possibility of ovary hyperstimulation…frequent visits
with HCP, checking estradiol levels and ultrasounds

• Repronex (2nd line if Clomid doesn’t work). Stimulates ovaries to produce eggs

• Bravelle(2nd line if Clomid doesn’t work). (FSH only)-inidcated if have excess

androgen production—helps equalize hormone ratio and induce ovulation.

Assistive Reproduction (ALWAYS GET CONSENT WHEN DOING PROCEDURES***)

Intrauterine Insemination (IUI) or Donor Insemination (DI)

Involves depositing sperm at the cervical os or in the uterus by mechanical means.

Can use sperm from the partner or from a donor. May be used if the male has problems with
anatomy that prevents sperm from depositing correctly and if female has factors that affect the
sperm once deposited.

InVitro Fertilization (IVF)

Eggs are collected from ovaries, fertilized in lab, and placed into uterus after
normal embryo development has begun. Usually several embryos are replaced to increase odds
of having successful pregnancy. Fertility drugs are used to induce ovulation and monitoring of
follicular growth is done and meds may be given to give the eggs the last boost of growth just
before retrieval. The eggs are then fertilized and allowed to progress to embryo stage and then
placed into uterus (usually 1-2 days after conception).
 GIFT (Gamete Intrafallopian transfer)

Oocytes are retrieved by laparoscopy and immediately placed with washed motile
sperm and the gametes are placed into the end of the fallopian tubes. Fertilization occurs in
fallopian tubes as with normal conception (in vivo). Then fertilized egg travels through tubes to
uterus for implantation.

ZIFT or TET (zygote intrafallopian transfer or tubal embryo transfer)

Eggs are retrieved and incubated with man’s sperm but are transferred back to
woman’s body earlier than with IVF. Are placed into fallopian tubes as with GIFT. With TET,
placement occurs at the embryo stage. With these, fertilization can be documented.

IVF with donor oocytes

This is for women who don’t produce viable eggs.

Gestational carrier/surrogate

Embryo cryopreservation – how excess embryos are stored.

ICSI-micromanipulation with specialized instruments under a microscope and inject

sperm cell directly into egg, useful with severe male factor infertility.

Nursing Management of Infertility****will further discuss these in class******

Counselor (listen, support, evaluate and reevaluate, reassure that they are feeling normal
feelings)

Educator (teach enough to make informed decisions, reinforce or restate, evaluate)

Advocate (be their advocate)

Pregnancy after dealing with infertility

May feel sense of loss and isolation because those without trouble can’t relate to physical
and emotional pain they endure

May question whether treatment affected the baby

Need reassurance to help allay anxiety

THE MENSTRUAL CYCLE

Menstruation is due to cyclic hormonal changes. This occurs when the ovum is not
fertilized and begins about 14 days after ovulation (with a normal 28 day cycle). Cycles range
from 21-35 days normally and last between 2 to 8 days. Factors that can affect the menstrual
cycle are illness, stress, excessive exercise, drastic weight changes, etc.

Menstrual phase (days 1-6) mensces occurs, estrogen levels are low.

Proliferative phase (days 7-14) endometrium begins to thicken due to increasing

estrogen which will peak just before ovulation

Secretory phase (days 15-26) follows ovulation. Estrogen drops and

progesterone dominates. Uterus is made ready for implantation

Ischemic phase (days 27-28) begins if fertilization doesn’t occur. Corpus luteum
degenerate and both estrogen and progesterone levels fall.

THE OVARIAN CYCLE

Follicular phase (days 1-14, this is part that varies in women). As FSH and LH
increase, 6-12 follicles begin to grow. 1 will outgrow the others. The mature one secretes large
amounts of estrogen which will decrease FSH levels. Approximately 2 days before ovulation,
LH will increase. Increase in progesterone and decrease in estrogen (stimulates final
maturation). Luteal phase (days 14-28) begins when ovum leaves follicle (ovulation). Corpus
luteum prepares endometrium in case implantation occurs, if not it will regress (decrease in
estrogen and progesterone) and LH and FSH will increase.