GOVERNMENT COLLEGE

OF NURSING, JODHPUR
(RAJ.)

ASSIGENMENT
ON
INFERTILITY
Subject-Obstetrics & Gynaecology Specialty-I

SUBMITTED TO - SUBMITTED BY-

Mrs. ANNMA SUMON PRIYANKA GEHLOT
NURSING LECTURER M.sc (N) Pre. Year
GCON, Jodhpur GCON, Jodhpur
 INTRODUCTION
Every person in life experiences happiness and sadness. There are certain moments which
always remain memorable. Pregnancy is the unforgettable period in every woman’s life. It
brings happiness, completeness and responsibility in her. The desire to give birth to nurture a
baby & to experience parenthood is basic human desire therefore impaired fertility gives a
couple sadness for a lifetime.
In addition, a couple may not realize the extent and cost of the process of diagnosis
and treatment when they seek assistance for their inability to conceive recommended
treatments and supportive care needed for impaired fertility

DEFINITION
Fertility is defined as the capacity to conceive or reproduce.
Infertility is defined as a failure to conceive within one or more years of regular unprotected
coitus.
Infertility is the inability to achieve conception after one year of unprotected intercourse.

INCIDENCE
According to statistics collected by the Centers for Disease Control (CDC), 6.1 million
women between the ages of 15 to 44 have an impaired ability to have children, and 2.1
million married couples are experiencing infertility.
The statistical study also found that 9.2 million women had made use of infertility services at
some time in their life.
WHO survey report 2000 reveals the incidence of infertility as 12-13.5 % among married
couples. 80 % of the couples achieve conception within one year of regular intercourse with
adequate frequency (4-5 times in a week) 10 % will achieve by the end of 2nd year and 10 %
will remain infertile by the end of 2nd year.

TYPES
1. Primary Infertility
When a couple has never been pregnant either the woman has never conceived or the man has
never fathered a child.

2. Secondary Infertility
Secondary infertility refers to women who have achieved pregnancy and given birth in the
past, but is now having difficulty conceiving.

3. Idiopathic infertility
“It is defined as inability of a couple to conceive in the absence of any detectable
abnormality.”
No definite cause for the infertility can be found.

4. Recurrent Miscarriage
Women who experience recurrent miscarriages may also receive a diagnosis of infertility if
they experience two or more successive miscarriages.

CAUSES OF INFERTILITY

1. ENDOMETRIOSIS -1/3rd of infertile women have endometriosis.

2. TUBAL BLOCKAGE
Due to PID because it leaves scar tissue & adhesions as a result of inflammation tubes may
be kinked or twisted.

3. PREVIOUS SURGERY
Previous surgery like appendectomy, repair of a tube after ectopic pregnancy may cause
adhesions or scaring.

4. Use of IUD or progesterone only oral contraceptives increases risk of ectopic pregnancy.

5. OVULATION ANOMALIES (ANOVULATION)

Failure of the ovaries to produce, mature or release eggs is an imbalance of hormones.

6. CERVICAL MUCOUS PROBLEMS

Hormonal deficiencies that maintain the thick acidic property of cervical mucus so it is
hostile to sperm.

7. INSUFFICIENT OESTROGEN & PROGESTERONE PRODUCTION

Excessive androgen production increased or decreased FSH, LH Levels. The production FSH
stimulates follicle to ripen & causes the production of Progesterone & production of estrogen.

8. IMMUNOLOGIC FACTORS
It may cause antigen in semen & in the acrosome, midpiece & tail of sperm. Antibodies are
produced against these antigens and it may cause infertility in the women.

9. VARICOCELE
Is a varicose or swollen vein in the testicle. Swelling elevates the temperature within the
testis. It retards or destroys the process of spermatogenesis.

10. COMBINED CAUSES – If women have partially blocked fallopian tubes and motility of
her partner’s sperm is poor then fertilization is unlikely to occur.

CAUSES OF FEMALE INFERTILITY

DEFECTIVE OVULATION
Endocrine disorders
 Dysfunction of
 Hypothalamus
 Pituitary
 Adrenals
 Thyroid

 Systemic disease
Diabètes mellites
 Coeliac diésasse
RénalFailure

 Physical disorders
 Obesity
  Anorexia nervosa or strict dieting
 Excessive exercise

 Ovarian disorders
 Hormonal
 Ovarian cysts or tumors
 Poly cystic ovary disease
 Ovarian endometriosis
Defective transport of Ovum

 Tubal obstruction
 Infection (gonorrhea, peritonitis, pelvic inflammatory disease)
 Previous tubal surgery

Fimbriae adhesions
 Previous surgery
 Endometriosis
 Sperm

 Vagina
 Psychosexual problems (Vaginismus)
 Infection (Causing dyspareunia)
 Congenital anomaly

 Cervix
 Cervical trauma or surgery (cone biopsy)
 Infection
 Hormonal (hostile mucus)
 anti-sperm antibodies in mucus

 Defective implantation
 Hormonal imbalance
 Congenital anomalies
 Fibroids
 Infection

CAUSES OF MALE INFERTILITY

DEFECTIVE SPERMATOGENESIS
Endocrine disorders
 Dysfunction of
 Hypothalamus
 Pituitary
 Adrenals
 Thyroid

 Systemic disease
 Diabetes mellitus
 Coeliac disease
 Renal failure
  Testicular disorders

 Trauma

 Environmental (High temperature)

 Congenital (hydrocele, undescended testes)
 Occupational (furnaceman, long-distance lorry driver)
 Acquired (Varicocele, tight clothing)

 Cancer treatment

Defective transport
 Obstruction or absence of seminal ducts
 Infection
 Congenital anomalies
 Trauma

 Impaired secretions from prostate or seminal vesicles:

 Infection
 Metabolic disorders
 Ineffective delivery

 Psychosexual problems (impotence)

 Drug-induced (ejaculatory dysfunction)

 Physical disability

 Physical anomalies
 Hypospadias
 Epispadias
 Retrograde ejaculation(into bladder)

FACTORS RESPONSIBLE FOR INFERTILITY

Before a specific method for treating infertility are selected factors

Contributing to fertility must be explored to the couple.

1. Coital frequency – Unprotected intercourse more than three times a week offers the
best opportunity for conception to occur, whereas daily intercourse may result in decreased
volume of ejaculate and a low sperm count. Planning intercourse around the time of ovulation
is essential because the ova can only be fertilized within 24 hours after ovulation. Sperm
leaves for 48 to 120 hrs.

2. Age – Coital frequency often decreases as marriage length increases and as women
ages medical conditions that interfere with pregnancy may develop. The women older than
35 years has a decreased chance of successful conception.

3. Smoking – In Vitro studies have been conducted regarding the effect of nicotine on
ovulation. Cigarette smoking increases the peristalsis within the fallopian tubes causing the
ovum to pass more quickly. This also increases the risk of ectopic pregnancy. Heavy cigarette
smoking has been associated with poor pregnancy outcomes and may play a role in impaired
fertility.

4. Exercise and weight loss – Heavy exercise has been associated with menstrual
irregularity and excessive weight loss can cause amenorrhea. High scrotal temperature from
Sauna or hot tub use or tight nylon underpants can decrease male sperm production.

5. Diet – A deficiency in vitamin B12 has been linked to infertility in some studies. A
low calorie, strict vegetarian diet has a possible relationship by altering the luteal phase and
the release of gonadotropins. Obese women are at risk for ovulatory dysfunction and
infertility.

6. Stress – Infertile women may be expected to have high stress and anxiety levels
concerning their inability to conceive. Women who seek treatment for infertility may be more
anxious or stressed. Some religious groups require successful pregnancy for heirs to maintain
or continue the marriage. Listening to the couple and providing referral to a priest or religious
leader, social worker or support group are helpful.

7. Medical conditions – pelvic adhesions and a history of previous pelvic inflammatory

disease (PID) or endometriosis may affect fertility. Abdominal surgery can influence tubal
patency. Abnormalities of the reproductive tract in the women or her partner and
immunologic and endocrine disorders can also alter fertility and require treatment before
fertility therapy is started.

8. Use of drugs and chemicals – Repeated workplace exposure to chemicals such as

nitrous oxide and soil fumigants. Drugs such as antihistamines can reduce vaginal lubrication,
anti-hypertensive impair male erection, barbiturates can inhibit hormone release and non-
steroidal anti-inflammatory drugs can inhibit ovulation.

Factors related to sperm and ovulation

1. Healthy spermatozoa – Should be deposited high in the vagina at or

near the cervix(male factor)

2. The spermatozoa should undergo changes (capacitation, acrosomereaction) and acquire

motility. (Cervical factor)

3. The motile spermatozoa should ascend through the cervix into theuterine cavity and the
fallopian tubes.

4. There should be ovulation. (Ovarian factor)

5. The fallopian tubes should be patent and the oocyte should be picked up by the
fimbriated end of the tube. (Tubal factor)

6. The spermatozoa should fertilize the oocyte at the ampulla of the tube.

7. The embryo should reach the uterine cavity after 3-4 days offertilization.
 8. The endometrium should be receptive for implantation and the corpus Luteum should
function adequately.

INVESTIGATIONS OF INFERTILITY
Objectives of investigations
♦ To detect the etiological factors.
♦ To rectify the abnormality in an attempt to improve the fertility.
♦ To give assurance with explanation to the couple if no abnormality is detected.

The infertile couple should be investigated after one year of regular unprotected exposure
with adequate frequency. The interval can be six months after the age of 35 of the women and
40 years of man.

The basic investigations to be carried out are –

 Confirmation of ovulation.
The various methods used to detect are indirect, direct and conclusive.

Indirect causes-
1. Menstrual history & Physical Exam
♦ Abnormalities of pelvic organs, congenital absence oforgans undescended
testis and varicocele
♦ LMP, Sexual Activity
♦ Surgery
♦ Medical symptoms
♦ Menopause and reproductive history
♦ BMI
♦ Thyroid
♦ Skin
♦ Breast

2. Basal Body Temperature (BBT) Assessment

The women take her temperature with a special thermometerevery morning before getting out
of bed.
The BBT will increase very slightly at ovulation & remain increased until menstruation or
pregnancy occurs Many factors affect the BBT and may cause inaccurate interpretation of the
reading such as use of a heated water bed, use of alcohol fatigue and infection.
Daily BBTS are taken in the same manner as for fertility control.
BBT is used with notation by the couple on the frequency of intercourse and symptoms
experienced during the cycle.Evidence of follicle development, ovulation & corpus luteum
development would be apparent if the temperature change persisted for 12-14 days before
menses.
Temperature chart for at least 4 cycles.
An endometrial biopsy, serum progesterone level & ovulation index it includes urine stick
test it determines if the surge in LH that precedes follicular rupture has occurred.

3. Cervical factor
Cervical mucus method (Also known as the billing method or ovulation method) After
ovulation the cervical mucus becomes thick & sticky and can be stretched between the
fingers.(A sign known as spin barkeit) If the mucus is mixed with semen or contraceptive
foams or an infection is present, the result may be inaccurate. Some women may feel
uncomfortable touching their genitals and mucus.
Cervical mucus examined at ovulation & after intercourse to determine whether changes
occur that promote sperm penetration &cervical.

4. Rhythm Method
Is also known as the calendar method.This method is based on a calendar documentation of
the woman’s menstrual cycles calculation of the fertile period of the woman. Intercourse is
then avoided during the fertile period. The calendar method assumes that ovulation occurs
approximately 14 days before the onset of the next menstrual period. Knowledge regarding
sperms is viable for 48 -120 hrs. and the ovum is visible for 24 hrs.The calendar method is
not a very reliable birth control technique because it requires c-operation and compliance by
both partners in keeping records of the menstrual cycle and abstaining when appropriate.

5. Hormone estimation
Serum FSH, LH, testosterone, prolactin, and TSH. Testicular dysfunction causes rise in FSH
and LH. Low level of FSH and LH suggest hypo-gonadotrophic hypogonadismElevated
prolactin due to pituitary adenoma may cause impotency.

6. Semen analysis
This should be the first step in investigation because it helps to detect some gross
abnormalities. (e.g. Absence of sperm), the couple should be counseled for the need of
assisted reproductive technology (ART).

Collection - The collection is best done by masturbation and if failed coitus interruptus. The
semen is collected in a clean wide mouthed dry glass jar. The sample collected should be sent
to thelaboratory as early as possible so that examination is possible within two hours. The
coitus should be avoided for 2-3 days prior to the test.

Normal values –
Volume 2.0 ml or more
PH 7.2 – 7.8
Sperm concentration 20 million / ml or more
Total sperm count > 40 million per ejaculate
Motility 50 % or more progressive forwardmotility
Morphology 15 percent or more normal form
Viability 75 % or more living
Leucocytes Less than 1 million / ml
Sperm agglutination < 2 (scale 0-3)

7. Testicular Biopsy-
Is done to differentiate primary testicular failure from obstruction as a cause of
azoospermia or severe oligospermia.

8. Tubal factor
Hysterosalpingography is used to rule out uterine or tubal abnormalities.Laparoscopy
permits direct visualization of the tubes & others pelvic structure. Identify conditions like
endometriosis etc.
 9. Uterine factors

For this pelvic examinations, hysteroscopy, saline sonogram (avariation of a sonogram)

&hysterosalpingography done.Fibroid, polyps & congenital malformations are possible
conditions.

10. Transrectal ultrasound (TRUS)

Is done to visualize the seminal vesicles, prostrate, and ejaculatory ducts obstruction.

11. Immunological tests

Two types of antibodies have been described. The antibodies are produced following
infection,(Orchitis) trauma, or vasectomy.

12. Miscelleneous factor

a. Men urine analysis after ejaculation
Blood tester one
FSH, LH
Prolactin level
Anti-sperm & antibodies
b. Female blood sampling FSH, LH, TFT, LTH, Prolactin level
USG to identify pelvic abnormality cysts masses or foreign objects such as lost IUD etc.

ADVANCED MANAGEMENT OF INFERTILITY

ETHICAL AND LEGAL ISSUES
Clinical education is an important nursing function & negligence may be found if the nurse
fails to ensure that the client is known legible about the treatment.

1. Artificial insemination by donor -

It is done with consent of her husband the woman’s husbandreplaces the genetic
father as the legal father of the child and adoption is not necessary in most states.
So almost require consent by husband of woman who is to beimpregnated and release
the sperm donor from parental rights and duties.

2. Surrogacy -
It is more complex because it involves three women.
A. Genetic mother, who donates ovum,
B. Gestational mother who carries foetus,

C. Rearing mother who brings up the child.

The fathers female partner adapts the infant and become the mother.
The surrogate mother has often paid for her service and later on baby will be away from the
surrogate mother so necessity for legislation on surrogacy issues being debated include
payment
to gestational mother, creation of a waiting period after births and before birth the contract is
final and the obligation of the father and his partner if the infant is born with a birth defect.

3. Embryo transfer-
The issues are if test tube embryos have rights of human infants or can be treated as
properly. (Issues concerning frozen embryo still need to be addressed in united states)
 Embryos frozen for a specific purpose should be allowed to flow after this purpose is
fulfilled also argued that frozen embryos should not be bought or sold.
The reproductive technologies although achieving goal for many infertile couples are fought
with ethical dilemmas for all concerned

So, issues arise relating to the welfare of the child, the ages of the prospective partners,
anonymity of donors, the child rights to know about its genetic origins and surrogacy to name
but a few.

Issues related to over stimulation is selective early abortion recommended by the donors
when three or more ovum have been fertilized the reason is to promote growth of remaining
embryos because quadruplets and quintuplets are very premature and thus have many
physical problems. Issues related donor insemination that is use of only one donor for each
attempt screening the donor for genetic defects, infectious process, drug abuse and blood
type. The couple requesting artificial insemination consent and a contract accepting the
resultant offspring as their legal hair etc.

ROLE OF A NURSE IN INFERTILITY MANAGEMENT

1. A nurse will be involved with couples who undergoing fertility treatment but when a
successful conception is achieved the maternity services will be involved.

2. A nurse should be aware of the types of treatment that are currently available and
stresses that the couple has endured during the process.

3. A nurse should have a sufficient knowledge of the current fertilizing treatment and
understand procedures involved and remove the pressure of couple the procedure.

4. Reduce stress in relationship, encourage co-operation protect privacy, refer couple to

appropriate resource when necessary.

5. Advice to couple that is smoking is avoided because it has adverse effect on success
of reproduction, diet, exercise, stress reduction techniques, health maintenance and
disease prevention are beingemphasized in many infertility programs etc.

NURSING PROCESS
1. Assessment-
 Statement by either partner signs of depression or anxiety etc
 Lack of awareness of casts and process to the couple.
 Lack of follow through on testing instruction.

2. Nursing diagnosis
 Self-esteem disturbances related to inability to have a child.
 Potential knowledge deficit related to process of workup or outcome.
 Potential for noncompliance by one or both partner related resistance to the testing
regimen or invasion of privacy.

3. Expected outcome-
 Couple will express feelings because rapport with nurses.
 Attend counseling sessions to explore impact of infertility on their life partner plans.
  Couple will give evidence of complying with plan of care by following directions for
home routine attendance.
 Couple will adhere to medication regimen.

4. Nursing treatment-
 Encourage discussion of feelings and reasons for seeking assistance.
 Establish rapport with couple and health care team.
 Discuss sources of outside support, including family and social or religious support
groups with couple.
 Encourage a counseling group if support is lacking.
 Determine the couple’s knowledge about self-care for preventing STUDS, infections
and exposure to noxious substances.
 Share general helpful points on intercourse methods and promote fertility.
 Be careful to protect the couple’s privacy.

 Reassess the couples understanding of requirements of testing or treatment.

 Suggest and ask for frank sharing of frustration.

5. Evaluation
 Couple expressed positive self-esteem.
 Couple used support resources as needed and considered alternatives both partners
indicated that these were no unanswered questions.
 Couple complied with prescribed plan of care.

BIBLIOGRAPHY
1. Christine Henderson & Kathlean tones, essential midwifery,mosby London
Philadelphia, St. Louis Sydeney, Pp 52-59
2. Diave M.Fraser Margartet A Copper, myles textbook for midvivse, 14th edition,
publiciation Churchill livingstone, Pp 174-180
3. Dickson Schalt, maternal infant nursing care, Mosby company publishers 1990 Pp
no.627-628.
4. D.C.Datta textbook of Gynaecology, 5th edition, New Central Book Agency, Pp no.
220 – 249.
5. Gynaecology by 10 teachers 18th edition Book power publishers Pp.no. 76-88