NCM 109 LEC
PRELIMS 1ST SEMESTER
INFERTILITY
INFERTILITY
➢ INFERTILITY
→ inability to conceive a child or sustain a pregnancy
to birth.
➢ SUBFERTILITY
→ have the potential to conceive but are just less able to
conceive without additional help
→ affects as many as 8% to 12% of couples who desire
children
→ said to exist when a pregnancy has not occurred
after at least 1 year of engaging in unprotected coitus
• PRIMARY SUBFERTILITY
→ no previous conceptions
• SECONDARY SUBFERTILITY
→ there has been a previous viable pregnancy but
the couple is unable to conceive at present
➢ CAUSES OF SUBFERTILITY
• 40% OF COUPLES
→ cause is multifactorial (more than one reason is
involved)
• 30% OF COUPLES
→ man who is subfertile
• 70% OF COUPLES
→ woman who is subfertile
• WOMEN SEEN FOR A FERTILITY EVALUATION
→ 20% to 25% experience ovulatory failure
→ another 20% experience tubal, vaginal, cervical,
or uterine problems
• IN ABOUT 10% OF COUPLES
→ no known cause for subfertility
➢ STERILITY
→ inability to conceive because of a known condition,
such as the absence of a uterus.
➢ ENGAGE IN COITUS ABOUT FOUR TIMES PER WEEK
→ 65% to 75% of couples will conceive within 6 months
→ 90% within 12 months
→ longer if sexual relations are less frequent
➢ COUPLES WHO ENGAGE IN COITUS DAILY
→ more difficulty conceiving than those who space
coitus every other day
➢ TOO-FREQUENT COITUS
→ can lower a man’s sperm count to a level below
optimal fertility
➢ AGE
→ related to subfertility
➢ GRADUAL DECLINE IN FERTILITY
→ women who defer pregnancy into their late 30s are
apt to have more difficulty conceiving
➢ WOMEN WHO ARE USING ORAL, INJECTABLE, OR
IMPLANTED HORMONES FOR CONTRACEPTION
→ may have difficulty becoming pregnant for several
months after discontinuing these medications
1| P a g e
FERTILITY ASSESSMENT
➢ IF A WOMAN IS YOUNGER THAN 35 YEARS OF AGE
→ usually suggested she have an evaluation after 1 year
of subfertility.
➢ IF A WOMAN IS OLDER THAN 35 YEARS
→ she should be seen after 6 months
→ REFERRAL is recommended sooner because assisted
reproductive strategies such as IVF, as well as
common alternatives to natural childbearing such
as adoption, are also limited by age
➢ If the couple is extremely apprehensive or knows of a
specific problem that could be causing their
difficulty in conceiving, studies should never be
delayed, regardless of the couple’s age
➢ Because most fertility tests are conducted in
ambulatory settings, nurses play key roles on
fertility teams to help achieve this goal, such as:
• Educating couples about the variety of tests and
procedures that may be performed
• Helping patients identify and express their
feelings about their desire to have a child
• Helping patients express how far they are
willing to go in testing and procedures to
achieve a child or how they might feel if, at the end
of testing, it is revealed pregnancy will not be
possible
• Assuming responsibility for health assessment,
patient education, and counseling
• Helping educate couples about advanced
techniques of assisted reproduction, many of
which are complex and demand knowledgeable,
ongoing involvement from the couple
• Counseling patients about available alternatives
when pregnancy cannot be achieved, such as
adoption or child-free living
➢ BASIC FERTILITY ASSESSMENT
→ begins with a health history and physical examination
of both sexual partners
HEALTH HISTORY
➢ Most couples assume subfertility is the woman’s
problem
PHYSICAL ASSESSMENT
➢ BOTH MEN AND WOMEN
→ need a complete physical examination
➢ MEN
• whether secondary sexual characteristics, such
as pubic hair, are present
• no genital abnormalities, such as the absence of
a vas deferens
NCM 109 LEC
PRELIMS 1ST SEMESTER

INFERTILITY
• presence of undescended testes • assays for FSH, estrogen, LH, and serial
• presence of varicocele progesterone levels
→ enlargement of a testicular vein • serum prolactin level
• if hydrocele is present, it should also be → If a woman has a history of galactorrhea (breast
documented. milk secretions)
→ collection of fluid in the tunica vaginalis of the → increased prolactin levels reduce the secretion of
scrotum pituitary hormones
→ rarely associated with subfertility
➢ WOMEN FACTORS THAT CAUSE MALE SUBFERTILITY
• BREAST AND THYROID EXAMINATION ➢ DISTURBANCE IN SPERMATOGENESIS
→ rule out current illness → production of sperm cells
• SECONDARY SEX CHARACTERISTICS ➢ INADEQUATE PRODUCTION OF FSH AND LH IN THE
→ indicate maturity and suggest good pituitary PITUITARY
function → which stimulates the production of sperm
• COMPLETE PELVIC EXAMINATION, INCLUDING A ➢ OBSTRUCTION IN THE SEMINIFEROUS TUBULES,
PAP TEST DUCTS, OR VESSELS
→ rule out anatomic disorders and infection → which prevent the movement of spermatozoa
➢ QUALITATIVE OR QUANTITATIVE CHANGES IN THE
FERTILITY TESTING
SEMINAL FLUID
➢ BASIC FERTILITY TESTING IS GEARED TOWARD → which prevent sperm motility (movement of sperm)
ANSWERING THREE QUESTIONS: ➢ DEVELOPMENT OF AUTOIMMUNITY
• Is there sperm of good quality and number → which immobilizes sperm
available? ➢ PROBLEMS IN EJACULATION OR DEPOSITION
• Are ova (eggs) available (i.e., woman is ovulating)? → which prevents spermatozoa from being placed close
• Is it possible for the sperm and egg to meet in a enough to a woman’s cervix to allow ready
receptive environment? penetration and fertilization
➢ TO ANSWER THESE QUESTIONS, ONLY THREE TESTS ➢ CHRONIC OR EXCESSIVE EXPOSURE TO X-RAYS OR
ARE COMMONLY USED: RADIOACTIVE SUBSTANCES, GENERAL ILL HEALTH,
• semen analysis in men POOR DIET, AND STRESS
• ovulation monitoring and tubal patency → all of which may interfere with sperm production
assessment in women
➢ ADDITIONAL TESTING FOR MEN LIMITED SPERM COUNT
• Urinalysis ➢ SPERM COUNT
• complete blood count → number of sperm in a single ejaculation or in a
• blood typing, including Rh factor milliliter of semen
• a serologic test for syphilis ➢ THE MINIMUM SPERM COUNT CONSIDERED NORMAL
• a test for the presence of HIV HAS:
• erythrocyte sedimentation rate • 33 to 46 million sperm per milliliter of seminal
→ an increased rate indicates inflammation fluid, or 50 million per ejaculation
• protein-bound iodine • 50% of sperm that are motile
→ a test for thyroid function • 30% that are normal in shape and form
• cholesterol level ➢ SPERMATOZOA
→ arterial plaques could interfere with pelvic blood → must be produced and maintained at a temperature
flow slightly lower than body temperature to be fully
• follicle-stimulating hormone (FSH), luteinizing motile
hormone (LH), and testosterone levels ➢ TESTES
➢ ADVANCED TESTING FOR WOMEN → sperm are produced and stored
• rubella titer → suspended in the scrotal sac away from body heat
• a serologic test for syphilis ➢ When scrotal heat raises, sperm count lowers
• an HIV evaluation ➢ WHAT LOWERS SPERM COUNT:
• a thyroid uptake determination

2| P a g e
NCM 109 LEC
PRELIMS 1ST SEMESTER
INFERTILITY
• Any condition that significantly increases body
temperature, such as a chronic infection from
tuberculosis or recurrent sinusitis
• Actions that directly increase scrotal heat, such as
working at a desk job or driving a great deal
every day
• Frequent use of hot tubs or saunas
• Congenital abnormalities (such as,
cryptorchidism)
• A varicocele, or varicosity (enlargement) of the
internal spermatic vein
➢ GENERAL PREVENTATIVE HEALTH MEASURE
→ Maintaining an ideal body weight
→ BMI: 18.5 to 24.9
➢ EXCESSIVE WEIGHT
→ may alter testosterone production and sperm
production
➢ CRYPTORCHIDISM
→ undescended testes
➢ VARICOCELECTOMY
→ surgical removal of the varicocele
→ may decrease warmth and improve fertility in some
men
➢ OTHER CONDITIONS THAT MAY INHIBIT SPERM
PRODUCTION INCLUDE:
• Past trauma to the testes
• Surgery on or near the testicles that has resulted
in impaired testicular circulation
• Endocrine imbalances, particularly of the thyroid,
pancreas, or pituitary glands
• Drug use or excessive alcohol use
• Environmental factors, such as exposure to X-
rays or radioactive substances
➢ MEN WHO ARE EXPOSED TO RADIOACTIVE
SUBSTANCES IN THEIR WORK ENVIRONMENT
→ should be provided with adequate protection of the
testes
TESTING FOR SPERM NUMBER AND AVAILABILITY
ANALYSIS OF PITUITARY HORMONES
➢ BLOOD TEST AND ANALYSIS
→ can determine whether adequate levels of FSH and LH
are present
➢ MAN HAVING TYPICAL MALE FEATURES:
→ limited sperm count is rarely a problem
SEMEN ANALYSIS
➢ EJACULATION FOR A SEMEN ANALYSIS
→ on average, it should produce a minimum of 1.4 to
1.7 ml of semen
→ should also contain a minimum of 33 to 46 million
3| P a g e
spermatozoa per milliliter of fluid
➢ SEMEN ANALYSIS INCLUDES THE FOLLOWING STEPS:
• The patient is instructed to be sexually abstinent
2 to 4 days prior to the analysis.
• The patient ejaculates by masturbation into a
clean, dry specimen jar or a special condom (one
without spermicide).
• The number of sperm in the specimen are
counted and then examined under a microscope
within 1 hour of ejaculation
SPERM PENETRATION ASSAY AND ANTISPERM ANTIBODY
TESTING
➢ NORMAL IMPREGNATION
→ for impregnation to take place, sperm must be
mobile enough to navigate the vagina, uterus, and a
fallopian tube to reach the ova
➢ INTRACYTOPLASMIC SPERM INJECTION
→ an assisted reproductive technique
→ poorly mobile sperm or those with poor penetration
can be injected directly into a woman’s ovum under
laboratory conditions bypassing the need for sperm to
be fully mobile.
THERAPY FOR INCREASING SPERM COUNT AND
MOTILITY
➢ IF SPERM ARE PRESENT BUT THE TOTAL COUNT IS
LOW
→ may be advised to abstain from coitus for 7 to 10 days
at a time to increase the count
➢ MAY ALSO HELP REDUCE SCROTAL HEAT AND
INCREASE THE SPERM COUNT:
• Ligation of a varicocele
• changes in lifestyle
→ such as avoiding recreational marijuana use,
wearing looser clothing, avoiding long periods of
sitting, and avoiding prolonged hot baths
OBSTRUCTION OR IMPAIRED SPERM MOTILITY
➢ In some men, adequate sperm are manufactured, but
there is obstruction at some point along the pathway
spermatozoa must travel to reach the outside: the
seminiferous tubules, the epididymis, the vas deferens,
the ejaculatory duct, or the urethra
➢ DISEASES THAT RESULT IN THIS TYPE OF
OBSTRUCTION:
→ adhesions form and occlude sperm transport
• MUMPS ORCHITIS
→ testicular inflammation and scarring due to the
mumps virus
• EPIDIDYMITIS
→ inflammation of the epididymis
NCM 109 LEC
PRELIMS 1ST SEMESTER
INFERTILITY
• INFECTIONS
→ such as gonorrhea or ascending urethral
infection
• CONGENITAL STRICTURE OF A SPERMATIC DUCT
→ may occasionally be seen.
➢ BENIGN HYPERTROPHY OF THE PROSTATE GLAND
→ occurs in most men beginning at about 50 years of
age.
→ pressure from the enlarged gland on the vas deferens
can then interfere with sperm transport
➢ CHANGES THE COMPOSITION OF THE SEMINAL FLUID
ENOUGH TO REDUCE SPERM MOTILITY:
• INFECTION OF THE PROSTATE
→ through which the sperm and seminal fluid
must pass
• INFECTION OF THE SEMINAL VESICLES
→ spread from a urinary tract infection
➢ VASECTOMIES
→ few men who have this develop an autoimmune
reaction or form antibodies that immobilize their own
sperm after the procedure
→ may also experience long-term pain unless the
procedure is reversed
➢ OBSTRUCTION IN THE VAS DEFERENS FROM OTHER
CAUSES
→ such as scarring after an infection
→ could also develop an autoimmune reaction that
immobilizes sperm the same way.
➢ ANOMALIES OF THE PENIS THAT CAUSE SPERM TO BE
DEPOSITED TOO FAR FROM THE SEXUAL PARTNER’S
CERVIX TO ALLOW OPTIMAL CERVICAL PENETRATION
• HYPOSPADIAS
→ urethral opening on the ventral surface of the
penis
• EPISPADIAS
→ urethral opening on the dorsal surface
• PEYRONIE DISEASE
→ a bent penis
TESTING FOR SPERM TRANSPORT DISORDERS
➢ SPERM TRANSPORT DISORDERS ARE SUSPECTED
→ when FSH and LH hormones, are adequate but the
sperm count remains limited.
THERAPY FOR SPERM TRANSPORT DISORDERS
➢ SURGERY
→ if sperm are not able to pass through the vas
deferens because of obstruction
→ to relieve the obstruction
→ extensive, costly, and may not have a positive
outcome
➢ BETTER SOLUTION:
4| P a g e
→ extracting sperm from a point above the blockage
and injecting it into the vagina or uterus of the
man’s partner by intrauterine insemination (IUI)
➢ SPERM ARE IMMOBILIZED BY VAGINAL SECRETIONS
DUE TO AN IMMUNOLOGIC FACTOR
→ reduced by abstinence or condom use for about 6
months
→ to avoid this prolonged time interval, washing of the
sperm followed by IUI may be preferred.
➢ ADMINISTRATION OF CORTICOSTEROIDS TO A
WOMAN
→ may have some effect in decreasing sperm
immobilization because it reduces her immune
response and antibody production.
EJACULATION PROBLEMS
➢ ERECTILE DYSFUNCTION
→ formerly called impotence
→ inability to achieve an erection
→ may occur from psychological problems
→ difficult problem to solve if it is associated with
stress because this is not easily relieved
• PRIMARY
→ if the man has never been able to achieve
erection and ejaculation
• SECONDARY
→ if the man was able to achieve ejaculation in the
past but now has difficulty
➢ MAY RESULT IN ERECTILE DYSFUNCTION:
• cerebrovascular accident
• diabetes
• parkinson disease
• use of certain antihypertensive agents
• discontinuation of finasteride
→ a drug used for male pattern baldness
➢ PREMATURE EJACULATION
→ ejaculation before penetration
→ another factor that may interfere with the proper
deposition of sperm
→ another problem often attributed to psychological
causes
TESTING FOR EJACULATION CONCERNS
➢ EJACULATION CONCERNS
→ identified by a sexual history
→ may be difficult for a man to discuss this area of his
life, especially if a nurse is female, so skillful patient
interviewing technique is required.
THERAPY FOR EJACULATION CONCERNS
➢ SOLUTIONS FOR ERECTILE DYSFUNCTION
→ psychological or sexual counseling
NCM 109 LEC
PRELIMS 1ST SEMESTER
INFERTILITY
→ use of a phosphodiesterase inhibitor, such as
sildenafil (Viagra) or tadalafil (Cialis)
➢ DAPOXETINE
→ short-acting selective serotonin reuptake inhibitor
→ drug that has been developed especially for the
treatment of premature ejaculation
→ shows good results when taken about 1 hour before
planned coitus
FACTORS THAT CAUSE FEMALE SUBFERTILITY
➢ analogous to those causing subfertility in men
• LIMITED PRODUCTION OF FHS OR LH
→ which interfere with ova growth
• ANOVULATION
→ faulty or inadequate expulsion of ova
• PROBLEMS OF OVA TRANSPORT THROUGH THE
FALLOPIAN TUBES TO THE UTERUS
• UTERINE FACTORS
→ tumors or poor endometrial development
• CERVICAL AND VAGINAL FACTORS
→ which immobilize spermatozoa
• POOR NUTRITION
→ increased body weight, and lack of exercise
ANOVULATION
➢ absence of ovulation or release of ova from the ovary
➢ most common cause of subfertility in women
➢ may occur from a genetic abnormality such as Turner
syndrome (hypogonadism),
➢ results from a hormonal imbalance caused by a
condition such as hypothyroidism
➢ HYPOTHYROIDISM
→ interferes with hypothalamus-pituitary-ovarian
interaction.
➢ OVARIAN TUMORS OR POLYCYSTIC OVARY
SYNDROME
→ may also produce anovulation due to feedback
stimulation on the pituitary
➢ MAY CONTRIBUTE TO POOR OVARIAN FUNCTION:
• chronic or excessive exposure to X-rays or
radioactive substances
• general ill health
• poor diet
• stress
➢ IMPORTANT FOR ADEQUATE OVA PRODUCTION
• nutrition
• body weight
• exercise
→ they all influence the blood glucose/insulin balance
➢ GLUCOSE OR INSULIN LEVELS ARE TOO HIGH
→ can disrupt the production of FSH and LH, leading to
ovulation failure.
5| P a g e
➢ VITAMIN D
→ may also be instrumental in maintaining pituitary
hormone levels
➢ THE IDEAL BODY WEIGHT TO MAINTAIN
→ BMI: 18.5 to 24.9
➢ EATING SLOWLY DIGESTED CARBOHYDRATE FOODS
AND FIBER-RICH VEGETABLES
→ increase fertility
→ keeps insulin levels balanced
→ may prevent gestational diabetes when a woman
becomes pregnant
➢ EXERCISING 30 MINUTES PER DAY BY WALKING OR
DOING MILD AEROBICS
→ helps to regulate blood glucose levels and increase
fertility, complementing healthy eating habits.
➢ STRESS
→ may play a role in limiting ovulation as this may lower
hypothalamic secretion of the gonadotropin-
releasing hormone (GnRH), which then lowers the
production of LH and FSH, which leads to
anovulation.
➢ DECREASED BODY WEIGHT OR A BODY FAT RATIO OF
LESS THAN 10%
→ may occur in female athletes or in women who are
excessively lean or anorexic
→ can reduce pituitary hormones such as FSH and LH
and halt ovulation (hypogonadotrophic
hypogonadism)
➢ OVULATORY PATTERNS OR POLYCYSTIC OVARY
SYNDROME
→ a condition in which the ovaries produce excess
testosterone, thus lowering FSH and LH levels,
which then causes irregular and unpredictable
menstrual cycles
➢ POLYCYSTIC OVARY SYNDROME IS ASSOCIATED WITH
METABOLIC SYNDROME, WHICH IS DIAGNOSED IN
PATIENTS WITH:
• Waist circumference of 35 in. or more in women
• Fasting blood glucose over 100 mg/dl
• Serum triglycerides over 150 mg/dl
• Blood pressure over 135/85 mmHg
• High-density lipoprotein cholesterol over 50
mg/dl
• Development of hirsutism (unwanted body hair)
➢ METABOLIC SYNDROME
→ also associated with increased cardiac disease
TESTING FOR ANOVULATION
OVULATION MONITORING
➢ FASTEST WAY TO INVESTIGATE IF OVULATION IS
OCCURRING
→ measure the woman’s serum progesterone level
NCM 109 LEC
PRELIMS 1ST SEMESTER
INFERTILITY
during the luteal phase of her menstrual cycle
(about day 21 to day 28 of a typical cycle)
➢ SERUM PROGESTERONE LEVEL
→ if elevated, it implies a corpus luteum has formed
or ovulation has occurred
➢ LEAST COSTLY WAY TO DETERMINE A WOMAN’S
OVULATION PATTERN
→ to record her basal body temperature (BBT) for at
least 4 months
➢ BASAL BODY TEMPERATURE
→ to determine this, a woman takes her temperature
each morning, before getting out of bed or engaging
in any activity, eating, or drinking, using a special BBT
or tympanic thermometer.
→ plots this daily temperature on a B while noting any
conditions that might affect her temperature, such as
an infection or sleeplessness
➢ AT THE TIME OF OVULATION
→ BBT can be seen to dip slightly (about 0.5°F)
→ then rises to a level about 1 degree higher than her
preovulation temperatures
→ stays at that level until 3 or 4 days before the next
menstrual flow
→ increase in BBT marks the time of ovulation because it
occurs immediately after ovulation
➢ IF THE TEMPERATURE RISE DOES NOT LAST AT LEAST
10 DAYS
→ suggests a woman has a luteal phase defect
OVULATION DETERMINITION BY TEST STRIP
➢ VARIOUS BRANDS OF COMMERCIAL KITS
→ available for assessing the upsurge of LH that occurs
just before ovulation
→ can be used in place of BBT monitoring.
→ a woman dips a test strip into a midmorning urine
specimen and then compares it with the kit
instructions for a color change.
→ purchased over the counter
→ advantageous for women with irregular work or
daily activity
→ can be also found online that contain materials to
test both FSH on the third day of a woman’s
menstrual cycle as well as sperm motility for the
male
→ test whether she has adequate FSH to stimulate egg
growth, therefore, should not be use during midpoint
of her menstrual cycle.
→ MAN’S RESULT: available in 10 minutes
→ WOMAN’S RESULT: available in 30 minutes
➢ ABNORMAL HIGH LEVEL OF FSH
→ an indicator her ovaries are not responding well to
ovulation
6| P a g e
➢ POLYCYSTIC OVARY SYNDROME
→ can be detected by examining the woman’s
menstrual history
→ even if a woman experiences regular monthly
menstruation, it does not necessarily indicate she is
also ovulating on a regular basis
→ fasting-glucose, testosterone, and estrogen levels
are analyzed
➢ PELVIC SONOGRAM
→ can be used to confirm cysts are present on the
ovaries and may be the cause of subfertility
THERAPY FOR ANOVULATION
➢ DISTURBANCE IN OVULATION IS IDENTIFIED AS THE
SUBFERTILITY CONCERN
→ administration of GnRH is a possibility to stimulate
the pituitary to secrete more FSH and LH
➢ THERAPY WITH CLOMIPHENE CITRATE (CLOMID) OR
LETROZOLE (FEMARA)
→ may also be used to stimulate ovulation
➢ OVARIAN FOLLICULAR GROWTH
→ can be stimulated by the administration of
combinations of FSH and LH in conjunction with
administration of human chorionic gonadotropin
(hCG) to produce ovulation
➢ INCREASED PROLACTIN LEVELS ARE IDENTIFIED
→ bromocriptine (Parlodel) is added to the medication
regimen to allow for the rise of pituitary
gonadotropins
➢ ADMINISTRATION OF EITHER CLOMIPHENE CITRATE
OR GONADOTROPINS
→ may overstimulate an ovary, causing multiple ova to
come to maturity, and possibly resulting in multiple
births
TUBAL TRANSPORT PROBLEMS
➢ DIFFICULTY WITH TUBAL TRANSPORT
→ usually occurs because scarring has developed in the
fallopian tubes
→ could also result from a ruptured appendix or from
abdominal surgery, which involved infection that
spread to the fallopian tubes and left adhesion
formation in the tubes
➢ SCARRING IN THE FALLOPIAN TUBES
→ typically caused by chronic salpingitis (chronic pelvic
inflammatory disease)
➢ COMPLETE TUBAL OBSTRUCTION
→ chief problem if a woman had a tubal ligation in years
past but now wants to become pregnant
➢ PELVIC INFLAMMATORY DISEASE
→ infection of the pelvic organs: the uterus, fallopian
tubes, ovaries, and their supporting structures
NCM 109 LEC
PRELIMS 1ST SEMESTER
INFERTILITY
→ initial source of the infection is usually a sexually
transmitted disease such as chlamydia or gonorrhea.
→ one-fourth of all women will experience this type of
infection in a lifetime.
→ about 12% of those who acquire PID will be left
subfertile because of tubal scarring
➢ PID INVASION OF FALLOPIAN TUBES
→ most apt to occur at the end of a menstrual period
because menstrual blood provides such an excellent
growth medium for bacteria
→ there also is a loss of the normal cervical mucus
barrier at this time, which increases the risk of initial
invasion
➢ PID LEFT UNRECOGNIZED AND UNTREATED
→ enters a chronic phase, which causes the scarring
that can lead to stricture of the fallopian tubes and
the resulting fertility problem
➢ HIGHER INCIDENCE OF PID AMONG WOMEN
→ multiple sexual partners
TESTING FOR TUBAL PATENCY
➢ ALL EFFECTIVE METHODS
• ultrasound or X-ray imaging
• direct visualization by a hysteroscope of
fallopian tubes
SONOHYSTEROSALPINGOGRAM
➢ sonographic examination of the fallopian tubes and
uterus
➢ uses an ultrasound contrast agent introduced into the
uterus through a narrow catheter inserted into the
uterine cervix followed by intravaginal scanning.
➢ IF THE TUBES ARE PATENT
→ will fill with the contrast medium and be detailed on
the ultrasound screen
➢ CONTRAINDICATIONS
• If there is a presence of infection of the vagina,
cervix, or uterus
→ infectious organisms might be forced through
the tubes into the pelvic cavity
➢ usually scheduled just following a menstrual flow
when a woman could not be pregnant.
➢ it does slightly distend the uterus and tubes, possibly
causing momentary painful uterine cramping.
➢ a chlamydia screen before the procedure is usually
advised because the procedure carries a small risk of
infection (happens rarely)
➢ an allergic reaction to the contrast medium or
embolism from the medium entering a uterine blood
vessel could also occur.
HYSTEROSALPINGOGRAM
7| P a g e
➢ similar to a sonohysterosalpingogram except a
radiopaque contrast medium is used and the fallopian
tubes are revealed by X-ray
➢ uses more contrast medium than with the sonogram
technique so the force of the injected solution may
actually break up tubal adhesions, and thus may be
therapeutic as well as diagnostic
➢ procedure must be scheduled immediately following a
menstrual flow when pregnancy could not be present
TRANSVAGINAL HYDROLAPAROSCOPY
➢ begun with the instillation of a paracervical local
anesthetic block followed by introduction of a
hysteroscope into an incision just behind the cervix
through the cul-de-sac of Douglas into the peritoneal
cavity
➢ about 200 ml of normal saline is then introduced to
move the bowel away from the uterus so the
posterior wall of the uterus, the ovaries, and the
fallopian tubes can be assessed
➢ TUBAL PATENCY
→ can be evaluated if, following the insertion of a small
amount of dye into the cervix, it can be viewed
exiting the fimbrial end of the tubes.
➢ AT THE END OF THE PROCEDURE
→ fluid is drained from the peritoneal cavity
→ small incision will heal without stitches
THERAPY FOR LACK OF TUBAL PATENCY
➢ SUBFERTILITY PROBLEM IS IDENTIFIED AS TUBAL
INSUFFICIENCY FROM INFLAMMATION
→ prescription of diathermy or steroid administration
may be helpful to reduce adhesions
➢ HYSTEROSALPINGOGRAPHY
→ instillation of a contrast dye under X-ray monitoring
→ can be attempted to see if the force of the dye
insertion will break adhesions
➢ OTHER POSSIBLE TREATMENTS
• Canalization of the fallopian tubes
• Plastic surgical repair (microsurgery)
➢ CAN BE REMOVED BY LAPAROSCOPY OR LASER
SURGERY
→ if peritoneal adhesions or nodules of endometriosis
are holding the tubes fixed and away from the ovaries
➢ It is possible for fallopian tubes, which have been
ligated as a contraception procedure, to be reopened
surgically but the success of the operation is not more
than 70% to 80%.
➢ IRREGULAR INCISION LINE LEFT BY SURGERY
→ can result in an ectopic pregnancy if a fertilized ovum
is stopped at the irregular point
➢ IVF
NCM 109 LEC
PRELIMS 1ST SEMESTER
INFERTILITY
→ more commonly used today
→ more apt to result in a viable pregnancy
UTERINE CONCERNS
➢ TUMORS SUCH AS FIBROMAS (LEIOMYOMAS)
→ may be a rare cause of subfertility if they block the
entrance of the fallopian tubes into the uterus or
limit the space available on the uterine wall for
effective implantation
➢ CONGENITALLY DEFORMED UTERINE CAVITY
→ may also limit implantation sites
→ also rare
➢ ENDOMETRIOSIS AND POOR SECRETION OF
ESTROGEN OR PROGESTERONE
→ more common uterine reasons for subfertility
→ these result in inadequate endometrial formation
(overproduction or underproduction), which then
interferes with implantation and embryo growth.
➢ ENDOMETRIOSIS
→ refers to the implantation of uterine endometrium,
or nodules, that have spread from the interior of the
uterus to locations outside the uterus
→ occurrence of this may indicate the endometrial
tissue has different or more friable qualities than
usual (perhaps due to a luteal phase defect) and
therefore is a type of endometrium that also does
not support embryo implantation as well as usual.
➢ ENDOMETRIOSIS SYMPTOMS
→ begin in adolescence
→ occurs in as many as 50% of women, usually from
reflux through the fallopian tubes at the time of
menstruation
➢ GROWTHS ON THE OVARIES
→ can displace fallopian tubes away from the ovaries,
preventing the entrance of ova into the tubes
➢ PERITONEAL MACROPHAGES
→ are drawn to nodules of endometrium
→ can destroy sperm
TESTING FOR UTERINE CONCERNS
HYSTEROSCOPY
➢ visual inspection of the uterus through the insertion
of a hysteroscope (a thin hollow tube) through the
vagina, cervix, and into the uterus
➢ to further evaluate uterine adhesions, malformations,
or other abnormalities such as fibroid tumors or
polyps that were discovered on sonogram imaging
➢ CHLAMYDIA SCREENING
→ required before the examination to avoid
introduction of bacteria into the uterus
UTERINE ENDOMETRIAL BIOPSY
8| P a g e
➢ may be used to reveal an endometrial problem, such
as a luteal phase defect.
➢ OVULATION HAS OCCURRED
→ if the endometrium sample removed by biopsy
resembles a corkscrew (a typical progesterone-
dominated endometrium) seen in the second half of
a menstrual cycle
➢ done 2 or 3 days before an expected menstrual flow
(day 25 or 26 of a typical 28-day menstrual cycle)
➢ AFTER A PARACERVICAL BLOCK AND A SCREEN FOR
CHLAMYDIA
→ a thin probe and biopsy forceps are introduced
through the cervix
→ may experience mild-to-moderate discomfort from
maneuvering the instruments
→ there may be a moment of sharp pain as the biopsy
specimen is taken from the anterior or posterior
uterine wall.
→ might notice a small amount of vaginal spotting
after the procedure.
→ POSSIBLE COMPLICATIONS:
• pain
• excessive bleeding
• infection
• uterine perforation
→ CONTRAINDICATIONS:
• if pregnancy is suspected
• if there is a presence of infection such as acute
PID or Cervicitis
→ FOR FOLLOW UP, CALL HER PRIMARY CARE
PROVIDER IF:
• develops a temperature greater than 101°F
• large amount of bleeding
• passes clots
→ tell the healthcare agency when she has her next
menstrual flow because this helps “date” the
endometrium and the accuracy of the analysis
LAPAROSCOPY
➢ to examine the position and state of the fallopian
tubes and ovaries
➢ introduction of a thin, hollow, lighted tube (a fiber
optic telescope or laparoscope) through a small incision
in the abdomen, just under the umbilicus
➢ allows an examiner to view whether the ovaries are
close enough to the fallopian tubes to allow an ovum
to enter
➢ rarely done unless the results of a
uterosalpingography are abnormal because it
involves general anesthesia
➢ scheduled during the follicular phase of a menstrual
cycle
NCM 109 LEC
PRELIMS 1ST SEMESTER
INFERTILITY
➢ POSITIONED IN A STEEP TRENDELENBURG POSITION
→ brings the reproductive organs down out of the pelvis
➢ CARBON DIOXIDE
→ usually introduced into the abdomen
→ to move the abdominal wall outward and to offer
better visualization.
➢ may feel bloating of the abdomen from the infusion of
the carbon dioxide after such a procedure
➢ IF SOME CARBON DIOXIDE ESCAPES UNDER THE
DIAPHRAGM
→ they may feel extremely sharp shoulder pain from
the pressure of the gas on the cervical nerves
➢ DURING THE PROCEDURE
→ contrast medium can be injected into the uterus
through a polyethylene cannula placed in the
cervix to assess tubal patency
➢ TUBES ARE PATENT
→ if dye will appear in the abdominal cavity
➢ IF FIMBRIA HAVE BEEN DESTROYED BY PID
→ chance for a normal conception is in doubt because
ova seem to be unable to enter a tube if fimbrial
currents are absent.
THERAPY FOR UTERINE CONCERNS
➢ PROBLEM OF SUBFERTILITY APPEARS TO BE A
LUTEAL PHASE DEFECT
→ can be corrected by progesterone vaginal
suppositories
→ begun on the third day of a woman’s temperature
rise and continued for the next 6 weeks (if pregnancy
occurs) or until a menstrual flow begins.
➢ MYOMA (FIBROID TUMOR) OR INTRAUTERINE
ADHESIONS
→ myomectomy, or surgical removal of the tumor and
adhesions, can be scheduled
→ if the growth is small, this can be done by a
hysteroscopic ambulatory procedure
➢ MYOMECTOMY
→ intrauterine device (IUD) may be inserted to
prevent the uterine sides from touching and forming
new adhesions
→ may be prescribed estrogen for 3 months as another
method to prevent adhesion formation
→ IUD can be easily removed in about 1 month’s time.
➢ FOR PROBLEMS OF ABNORMAL UTERINE
FORMATION, SUCH AS A SEPTATE UTERUS
→ surgery is also available
→ these defects are usually related to early pregnancy
loss, not initial subfertility
➢ ENDOMETRIOSIS
→ can be treated both medically and surgically
VAGINAL AND CERVICAL CONCERNS
9| P a g e
➢ AT THE TIME OF OVULATION
→ cervical mucus is thin and watery
→ can be easily penetrated by spermatozoa for a
period of 12 to 72 hours.
➢ IF COITUS IS NOT SYNCHRONIZED WITH THE TIME OF
OVULATION
→ cervical mucus may be too thick to allow
spermatozoa to penetrate the cervix
➢ INFECTION OR INFLAMMATION OF THE CERVIX
(EROSION)
→ can also cause cervical mucus to thicken so much
that spermatozoa cannot penetrate it easily or survive
in it
➢ STENOTIC CERVICAL OS OR OBSTRUCTION OF THE OS
BY A POLYP
→ may further compromise sperm penetration
→ rarely enough of a problem to be the sole cause of
subfertility
➢ A WOMAN WHO HAS UNDERGONE DILATATION AND
CURETTAGE (D&C) PROCEDURES SEVERAL TIMES OR
CERVICAL CONIZATION (CERVICAL SURGERY)
→ should be evaluated in light of the possibility that scar
tissue and tightening of the cervical os has occurred
➢ INFECTION OF THE VAGINA
→ can cause the pH of vaginal secretions to become
acidotic, thus limiting or destroying the motility of
spermatozoa
➢ SPERM-IMMOBILIZING OR SPERM-AGGLUTINATING
ANTIBODIES IN THE BLOOD PLASMA
→ act to destroy sperm cells in the vagina or cervix
TESTING AND THERAPY FOR VAGINAL AND CERVICAL
CONCERNS
➢ LOW-DOSE ESTROGEN THERAPY
→ if sperm do not appear to survive in vaginal
secretions because secretions are too scant or
tenacious
→ to increase mucus production during days 5 to 10 of
her cycle
→ conjugated estrogen (Premarin) is a type of
estrogen prescribed for this purpose.
➢ IF A VAGINAL INFECTION IS PRESENT
→ treated according to the causative organism based
on culture reports
➢ TRICHOMONIASIS AND MONILIASIS
→ vaginal infection that tends to occur
→ requires close supervision and follow-up
➢ IF THE WOMAN’S SEXUAL PARTNER IS THE SOURCE
OF INFECTION, AND IS REINFECTING HER
→ partner needs antibiotic therapy
➢ METRONIDAZOLE (FLAGYL)
→ caution women with this prescription for a
NCM 109 LEC
PRELIMS 1ST SEMESTER

INFERTILITY
Trichomonas infection
→ may be teratogenic early in pregnancy
→ should not be continued if the woman suspects she
has become pregnant

UNEXPLAINED SUBFERTILITY

➢ may be that the problem of one partner alone is not

significant, but when combined with a small problem
in the other partner, together, these become sufficient
to create subfertility

10 | P a g e