Module 6

I. Infertility
Infertility is the inability to conceive after at least 1 year of sexual intercourse at least four times per
week without contraception. Because most couples have the potential to conceive but they are just
less able to do this without additional help, the term subfertility is more often used today. Subfertility
is said to exist when a pregnancy has not occurred after at least 1 year of engaging in unprotected
coitus.
 Primary infertility – no previous history of either partner conceiving or impregnating.
 Secondary infertility – inability to conceive after a previous successful pregnancy.
Sterility is the inability to conceive because of a known condition, such as the absence of a uterus.
Couple who feels they need fertility testing consist of the following:
a. Married couples
b. Couple who plans to marry
c. Some desire to remain single but bear a child.
d. Lesbian, gay, bisexual, or transgender (LGBT) and want to have a child through
an assisted fertility method.
Some couples, because they are unaware of the average length of time it takes to achieve a
pregnancy, may worry that they are subfertile when they are not. When engaging in coitus an
average of four times per week, 50% of couples will conceive within 6 months, and 85% within 12
months. These periods will be longer if sexual relations are less frequent. Couples who engage in
coitus daily, hoping to cause early impregnation, may actually have more difficulty conceiving than
those who space coitus to every other day. This is because too-frequent coitus can lower a man’s
sperm count (number of sperm in a single ejaculation) to a level below optimal fertility. Also,
couples who focus their sexual relations
on trying to increase sperm/ovum exposure may find their lives governed by temperature charts
and “good days” and “bad days” to such an extent that their relationship suffers.
 The chance of subfertility increases with age. Because of this gradual decline in fertility, women
who defer pregnancy to their late 30s are apt to have more difficulty conceiving than their younger
counterparts.
Most couples can benefit from some practical information on how to increase their chances of
achieving conception on their own. The following are time-honored suggestions to help aid
conception.
 Determine the time of ovulation through the use of basal body temperature or analysis of
cervical secretions and then plan sexual relations for every other day around the time of
ovulation.
 Although frequent intercourse may stimulate sperm production, men need sperm recovery
time after ejaculation to maintain an adequate sperm count. This why coitus every other day,
rather than every day, during the fertile period will probably yield faster results.
 The male superior position is the best position for coitus to achieve conception because it
places sperm closest to cervical opening.
 The male should try for deep penetration so ejaculation places sperm as close as possible to the
cervix.
 Elevating a woman’s hips on a small pillow can facilitate sperm being deposited near the
opening to the cervix. A woman should remain on her back with knees drawn up for at least
20 minutes after ejaculation to help sperm remain near the cervix.
 Don’t use douching or lubricants before or after intercourse so vaginal pH is unaltered, which
can interfere with sperm mobility.
 Eat a diet high in slowly digested carbohydrates, low in saturated or trans fats, and moderate in
protein.
 Maintain a body weight that results in a body mass index between 18.5 and 24.9.
 Exercise about 30 minutes per day to help keep blood glucose and insulin levels stabilized.
 Choose a new activity the two of you can do together, such as learning how to bowl or ballroom
dance, so you can create an activity separate from planning a baby.
 However, despite the practical information given to the couple, this may still yield to poor results.
Identifying the contributing factors and with appropriate interventions, increases the chances the
couple will conceive.
II. Factors that cause Male infertility
The factors that most commonly lead to male subfertility include (Table 1):
Disturbance in spermatogenesis Inadequate production of FSH and LH in the pituitary, which
stimulates the production of sperm.
1. Chronic or excessive exposure to X-rays or radioactive substances, general ill
health, poor diet, and stress, all of which may interfere with sperm production.
B. Disturbance in the movement of sperm (sperm motility) and ejaculation problems
1. Obstruction in the seminiferous tubules, ducts, or vessels, which prevent the
movement of spermatozoa.
2. Qualitative or quantitative changes in the seminal fluid, which prevent sperm
motility.
3. Develop of autoimmunity, which immobilizes the sperm.

A. Limited Sperm Count

Spermatozoa must be produced and maintained at a temperature slightly lower than body
temperature to fully motile. This is why the testes, in which sperm are produced and
stored, are suspended in the scrotal sac away from body heat. Any conditions that slightly
increases body temperature may lower sperm count.
 Chronic infection from tuberculosis or recurrent sinusitis
 Working at a desk job or driving a great deal every day
 Frequent use of hot tubs or sauna
 Excessive weight
 Congenital anomalies
- Cryptorchidism (undescended testes)
- Twisted spermatic cord
- Varicocele or varicosity (enlargement of the internal spermatic vein)
  Past trauma to the testes
 Surgery on or near the testicle that has resulted in impaired testicular circulation.
 Endocrine imbalances, thyroid, pancreas, or pituitary glands
 Drug use of excessive alcohol use
 Environmental factors, such as exposure to X-rays or radioactive substances.
- Testing for Sperm Number and Availability
1. Analysis of Pituitary Hormones
A blood test and analysis can determine whether adequate levels of FSH and LH are
present.
2. Semen Analysis
Semen analysis includes the following steps:
a. The patient is instructed to be sexually abstinent 2 to 4 days prior to the analysis.
b. The patient ejaculates by masturbation into a clean, dry specimen jar or a special
condom.
c. The specimen is kept at body temperature while transporting it (usually placed on
the man’s chest)
d. In a laboratory, the number of sperm in the specimen are counted and
then examined under a microscope within 1 hour of ejaculation.
e. The analysis may need to be repeated after 2 or 3 months because spermatogenesis
is an ongoing process and sperm maturity is 30 to 90 days.
3. Sperm Penetration Assay and Antisperm Antibody Testing
Sperm penetration studies are used to determine if the sperm can penetrate the ovum
effectively.
- Therapy for increasing Sperm Count and Motility
If sperm are present but the total count is low, a man may be advised to abstain from coitus
for 7 to 10 days at a time to increase the count. The following intervention may help reduce
scrotal heat and increase sperm count.
1. Ligation of a varicocele
2. Change in lifestyle such as avoid recreational marijuana use
 3. Wearing looser clothing
4. Avoiding long periods of sitting
5. Avoid prolonged hot baths.
B. Obstruction or impaired Sperm Motility
Obstruction at some point along the pathway the spermatozoa must travel to reach the
outside may be the reason of subfertility. Some disease can cause obstruction because
adhesions form and occlude sperm transport:
1. Mumps or Mumps orchitis (testicular inflammation and scarring due to mumps virus
2. Epididymitis (inflammation of the epididymis)
3. Gonorrhea or ascending urethral infection.
4. Infection of the prostate and seminal vesicles
5. Obstruction may also be due to congenital stricture of the spermatic duct or benign
hypertrophy of the prostate gland occurs at 50 years of age.
6. Pressure from the enlarged gland on the vas deferens can then interfere with sperm
transport.

Semen analysis includes the following steps:

a. The patient is instructed to be sexually abstinent 2 to 4 days prior to the analysis.
b. The patient ejaculates by masturbation into a clean, dry specimen jar or a special
condom.
c. The specimen is kept at body temperature while transporting it (usually placed on
the man’s chest)
d. In a laboratory, the number of sperm in the specimen are counted and
then examined under a microscope within 1 hour of ejaculation.
e. The analysis may need to be repeated after 2 or 3 months because spermatogenesis
is an ongoing process and sperm maturity is 30 to 90 days.
4. Sperm Penetration Assay and Antisperm Antibody Testing
Sperm penetration studies are used to determine if the sperm can penetrate the ovum
effectively.
- Therapy for increasing Sperm Count and Motility
If sperm are present but the total count is low, a man may be advised to abstain from coitus
for 7 to 10 days at a time to increase the count. The following intervention may help reduce
scrotal heat and increase sperm count.
6. Ligation of a varicocele
7. Change in lifestyle such as avoid recreational marijuana use
8. Wearing looser clothing
9. Avoiding long periods of sitting
10. Avoid prolonged hot baths.
C. Obstruction or impaired Sperm Motility
Obstruction at some point along the pathway the spermatozoa must travel to reach the
outside may be the reason of subfertility. Some disease can cause obstruction because
adhesions form and occlude sperm transport:
7. Mumps or Mumps orchitis (testicular inflammation and scarring due to mumps virus
8. Epididymitis (inflammation of the epididymis)
9. Gonorrhea or ascending urethral infection.
10. Infection of the prostate and seminal vesicles
11. Obstruction may also be due to congenital stricture of the spermatic duct or benign
hypertrophy of the prostate gland occurs at 50 years of age.
12. Pressure from the enlarged gland on the vas deferens can then interfere with sperm
transport.

13. Vasectomies develop an autoimmune reaction or form antibodies that immobilize their
own sperm after the procedure.
14. Anomalies of the penis can cause sperm to be deposited too far from the
sexual partner’s cervix.
a. Hypospadias (urethral opening on the ventral surface of the penis)
b. Epispadias (urethral opening on the dorsal surface)
c. Peyronie disease (a bent penis)
15. Extreme obesity may also interfere with effective penetration and deposition.
- Testing for Sperm Transport Disorders
Sperm transport disorders are suspected when FSH and LH hormones, which stimulate the
production of sperm are adequate, but the sperm count remains limited.
- Therapy for Sperm Transport Disorders
1. Surgery to relieve obstruction.
2. Intrauterine insemination (IUI) – injecting the sperm into the vagina or uterus.
3. Corticosteroid for the woman to reduce her immune response and antibody production,
thus decreasing sperm mobilization.
D. Ejaculation Problems
1. Erectile dysfunction or the inability to achieve an erection (formerly called impotence)
may occur from:
a. Psychological problems
b. Cerebrovascular accident
c. Diabetes
d. Parkinson’s disease
e. Use of antihypertensive agents
f. Discontinuation of finasteride (drug used for male pattern baldness)
Two types of erectile dysfunction
1. Primary – if the man has never been able to achieve erection and ejaculation
2. Secondary – if the man was able to achieve ejaculation in the past but now
has difficulty.
2. Premature ejaculation (ejaculation before penetration) is another factor that may
interfere with the proper deposition of sperm.
- Testing for Ejaculation Concerns
Ejaculation concerns are identified by a sexual history. It 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
a. Psychological or sexual counseling
 b. Use of phosphodiesterase inhibitor: sildenafil (Vaigra) or tadalafil (Cialis)
c. Dapoxetine (selective serotonin reuptake inhibitor) one hour before coitus.
Table 1. Summary of Male infertility – Causes and Management
Causes Management
A. Limited Sperm Count Infection Semen Analysis
Hot environment Ligation of varicocele
Congenital anomalies Lifestyle change
Trauma Loose clothing
Surgery Change position
Drugs
Xray
B. Obstruction or Mumps, epididymis, Corticosteroids
impaired sperm Gonorrhea Antibiotics
motility Congenital anomalies Surgery
Vasectomies Intrauterine insemination
Obesity
C. Ejaculation problems Psychological problems Psychological and sexual
counselling
Sildenafil (Viagra)
Tadafil (Cialis)
Dapoxentine (SSRI)

III. Factors That Cause Female Subfertility

 Limited production of FHS or LH, which interfere with ova growth.
 Anovulation
 Problems of ova transport through the fallopian tubes to the uterus
 Uterine factors, such as tumors or poor endometrial development
 Cervical and vaginal factors, which immobilize spermatozoa.
 Poor nutrition, increased body weight, and lack of exercise, which may
compound these problems.
A. Anovulation
Anovulation, the absence of ovulation or release of ova from the ovary, is the most common
cause of subfertility in women. Factors contributing to anovulation are:
1. Hormonal imbalance such in hypothyroidism
 2. Polycystic ovary syndrome is associated with metabolic syndrome. This is a condition
wherein the woman is experiencing regular monthly menstruation but not necessarily
ovulating regularly. It is diagnosed in patients with:
a. Waist circumference of 35 in or more
b. FBS over 100 mg/dl
c. Serum triglycerides over 150mg/dl
d. Blood pressure over 135/85 mmHg
e. High density lipoprotein over 50 mg/dl
f. Hirsutism (unwanted body hair)
3. Chronic or excessive exposure to X-rays or radioactive substances
4. Turner syndrome (hypogonadism)
5. Malnutrition
6. Stress
7. Obesity and Hyperglycemia
8. Vit D deficiency
- Testing for Anovulation
1. Ovulation monitoring
a. Measure woman’s serum progesterone. It is elevated during luteal phase.
b. Record basal body temperature for at least 4 months. The 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. BBT usually can
be seen to dip slightly (about 0.5 degrees F), it rises to a level of 1 degree until 3 or 4
days which marks the time of ovulation (Fig. 1).
c. Ovulation Determination by test strip.
The strip assesses the upsurge of LH that occurs just before ovulation and can
be used in place of BBT monitoring. A woman dips a test strip into the
midmorning urine specimen and then compares it with the kit for a color
change.
 Figure 1. Ovulation.
- Therapy for Anovulation
1. Maintain ideal body weight.
2. Eating slowly digested carbohydrate food
3. Exercising 30 minutes per day
4. Stress reduction
5. Administration of drugs to stimulate ovulation:
a. GnRH
b. Clomiphene citrate (Clomid) or letrozole (Femara)
c. FSH and LH with HCG
d. Bromocriptine (Parlodel) to reduce prolactin levels and allow for the rise of pituitary
gonadotropins.
B. Tubal Transport Problems
Difficulty with tubal transport usually occurs because of scaring has developed in the
fallowing tubes. This condition may occur when:
Salpingitis is a chronic pelvic inflammatory diseases
- Testing for tubal patency
 1. Sonohysterosalpingogram
a. Sonographic examination of the fallopian tubes and uterus using an ultrasound
contrast agent introduced into the uterus through a narrow catheter inserted into
the cervix followed by intravaginal scanning (Fig.2). If the tubes are patent, they will
fill with the contrast medium and be detailed on the ultrasound screen.
b. It is usually scheduled just following a menstrual flow when the woman could not
be pregnant.
c. It is both therapeutic and diagnostic as the pressure of the solution could break up
adhesions as it passes through the fallopian tubes.
d. It is contraindicated if infection of the vagina, cervix, or uterus is present.
e. Health teaching after the procedure
- The woman will feel painful uterine cramping due to the small contrast that
distend the tubes during procedure.
- Report to the doctor the following
1. signs of infection such as fever and uterine pain
2. signs of allergic reaction to the contrast medium
3. difficulty of breathing due to embolism when the contrast medium
entering a uterine blood vessel.

Figure 2. Insertion of a contrast medium for a sonohysterosalpingogram. The contrast medium

outlines the uterus and fallopian tubes on sonogram to demonstrate patency.
 2. Hysterosalpingogram
The procedure is similar to a sonohysterosalpingogram except a radiopaque contrast
medium is used and the fallopian tubes are revealed by X-ray. The procedure uses more
contrast medium than with the sonogram technique so the force of the injected solution
1.
2. Ruptured appendix or abdominal surgery which involved infection that spread t the
fallopian tubes.
3. Tubal ligation
4. Pelvic inflammatory disease is infection of the pelvic organs. The initial source of the
infection is usually a sexually transmitted disease such as chlamydia or gonorrhea. When
left untreated, it causes scarring that can lead to stricture of the fallopian tubes.

may actually break up tubal adhesions, and thus may be therapeutic as well as
diagnostic.
3. Transvaginal Hydro laparoscopy
a. The installation 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.
b. About 200 ml of normal saline is introduced to move the bowel away from the
uterus so the posterior wall of the uterus, ovaries, and the fallopian tubes can
be assessed.
c. Tubal patency is evaluated if a small amount of dye exits the fimbriae ends of
the uterus.
d. The fluid is drained from the peritoneal cavity.
e. The small incision will heal without stitches.
- Therapy for Lack of Tubal Patency
1. Administer diathermy or steroid to reduce adhesions.
2. Hysterosalpingography to break adhesions.
 3. Canalization of the fallopian and plastic surgical repair (microsurgery)
4. Remove adhesions by laparoscopy or laser surgery.
5. Reopen ligated tubes if the couple wish to have children or suggest in vitro fertilization
as an alternative.
C. Uterine Concerns
1. Tumors such as fibromas (leiomyomas) if they block the entrance of the fallopian tube
or limit the space available on the uterine wall.
2. Congenitally deformed uterine cavity.
3. Endometriosis refers to the implantation of uterine endometrium, or nodules, that have
spread form the interior of the uterus to locations outside the uterus. Common sites of
endometrium spread to the fallopian tubes, the cul-de-sac of Douglas, the ovaries, the
uterine ligaments, and the outer surface of the uterus and bowel. Endometriosis occurs in
as many as 50% of women, usually from reflux through the fallopian tubes at the time of
menstruation.
Effects of the endometrial implants outside the uterus:
a. If viable particles of endometrium, which enters a tube, begin to proliferate, they can
cause tubal obstruction.

b. Growths on the ovaries can displace fallopian tubes away from the ovaries, preventing
the entrance of ova into the tubes.
c. Peritoneal macrophages, which are drawn to nodules of endometrium, can destroy
sperm.
 Figure 3. Common sites of endometriosis formation
Risk factors for Endometriosis
a. White nulliparous women
b. Familial tendency - daughters of women with endometriosis may develop symptoms of
dysmenorrhea early in life.
c. Deficient immunologic response
d. Excess estrogen production or a failed luteal menstrual phase.
e. Usually discovered at a higher than usual rate among women undergoing subfertility
testing.
Signs and Symptoms
a. Dysmenorrhea causes dysmenorrhea when the abnormal tissue responds to estrogen
and progesterone stimulation by swelling and then sloughing its layers in the same
manner as the uterine lining. This causes inflammation of surrounding tissue in the
abdominal cavity and an even greater release of prostaglandins.
b. Abnormal tissue in the pelvic cul-de-sac can cause dyspareunia (painful coitus) because
it puts pressure on the posterior vagina.
c. Subfertility may result if the fallopian tubes become immobilized and blocked by tissue
implants or adhesions, preventing peristaltic motion and transport of ova
 d. Pelvic examination may show that the uterus is displaced by tender, fixed, palpable
nodules.
e. Nodules in the cul-de-sac or on an ovary also may be palpable.
f. If the endometriosis is minimal, the girl will not experience related symptoms. If the
condition is moderate or extensive, she may experience extreme dysmenorrhea or
dyspareunia.
- Testing for Uterine Concerns
1. Hysteroscopy
It is a visual inspection of the uterus through the insertion of a hysteroscope (a thin
hallow tube) through the vagina, cervix, and into the uterus. This is helpful to further
evaluate uterine adhesions, malformations, or other abnormalities such as fibroid,
tumors or polyps that were discovered on sonogram imaging. Women are screened for
chlamydia before the examination to avoid introduction into the uterus.
2. Uterine Endometrial Biopsy
It may be used to reveal an endometrial problem.
a. It is done 2 or 3 days before an expected menstrual flow.
b. The patient will be screened for Chlamydia to avoid introduction to the uterus.
c. A paracervical block is performed.
d. A thin probe and biopsy forceps are introduced through the cervix.
e. There may be a moment of sharp pain as the biopsy specimen is taken from
the anterior or posterior uterine wall.
f. After the procedure, the woman may experience mild-to moderate discomfort from
maneuvering the instruments.
g. Possible complications: pain, excessive bleeding, infection, and uterine perforation.
h. The procedure is contraindicated if pregnancy is suspected, infection (PID or
cervicitis)
i. Infection and bleeding are the side effects of the procedure.
3. Laparoscopy
It is an introduction of a thin, hallow, lighted tube (a fiber optic telescope or
 laparoscope) through a small incision in the abdomen, just under the umbilicus to
examine the position and state of the fallopian tubes and ovaries. This allows an
examiner to view whether the ovaries are close enough to the fallopian tubes to allow
an ovum to enter. It is rarely done unless the results of a uterosalpingography are

abnormal because it involves general anesthesia, which is necessary because of the

pain caused by extensive maneuvering.
a. It scheduled during the follicular phase of menstrual cycle.
b. The woman is positioned in a steep Trendelenburg position (which brings the
reproductive organs down out of the pelvis)
c. Carbon dioxide is introduced into abdomen to move the abdominal wall outward
and offer a better visualization.
d. A contrast medium can be injected into the uterus through a polyethylene cannula
placed in the cervix to assess tubal patency (if tubes are patent, the dye will appear
in the abdominal cavity)
e. A scope may be passed directly into a fallopian tube to reveal information about
the presence and condition of the fimbria and tubal lining.
f. After the procedure, warn the woman that she may feel bloating of the abdomen
from the infusion of the carbon dioxide and a sharp abdominal pain from the
pressure of the gas on the cervical nerves.
- Therapy for Uterine Concerns
1. Progesterone vaginal suppositories to correct luteal phase defect given on the third day
of the woman’s temperature rise and continued for the next 6 weeks or until menstrual
flow begins.
2. Myomectomy or surgical removal of the tumor and adhesions.
3. IUD is inserted after surgical intervention to prevent uterine sides from touching and
forming a new adhesion.
4. Estrogen is given for 3 months as another method to prevent adhesion formation.
D. Vaginal and Cervical Concerns
 1. Infection or inflammation of the cervix can cause cervical mucus to thicken so much that
spermatozoa cannot penetrate it easily or survive it.
2. A stenotic cervical os or obstruction of the os by a polyp may further compromise sperm
penetration.
3. Infection of the vagina can cause the pH of vaginal secretions to become acidotic,
thus limiting or destroying the motility of spermatozoa.
4. Some women appear to have sperm-immobilizing or sperm agglutinating antibodies in their
blood plasma, which act to destroy sperm cells in the vagina or cervix.
- Testing and Therapy for Vaginal and Cervical Concerns

1. Low-dose estrogen therapy (Conjugated estrogen: Premarin) to increase mucus

production during days 5 to 10 of her cycle.
2. Treat vaginal infection accordingly both for the woman and the partner to prevent
reinfection.
Table 2. Summary of Female Subfertility – Causes and Management
Causes Management
A. Anovulation Hormonal imbalance Ovulation monitoring
Ovarian tumors, PCOS Maintain ideal body weight.
Radioactive exposure Drugs: GnRh, Clomid, FSH, LH
Turner syndrome with HCG, Parlodel (LH, FSH)
Malnutrition, stress, obesity
Hyperglycemia, Vit. D deficiency
B. Tubal transport Salpingitis, ruptured appendix, Sonohysterosalpingogram
problems tubal ligation, PID Hysterosalpingogram
Steroid
Surgery
C. Uterine Tumors (myoma) Hysteroscopy
concerns Congenitally deformed uterus Uterine endometrial biopsy
Endometriosis Transvaginal
hydrolaparoscopy
Myomectomy
IUD to prevent adhesions
D. Vaginal and Infection, stenotic cervical OS Premarin
cervical Acidic vaginal pH Treatment of infection
concerns Sperm antibodies Steroids
IV. Unexplained Subfertility
In a small percentage of couples, no known cause for subfertility can be discovered. It 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.
V. Assisted Reproductive Techniques
Assisted reproductive strategies are the next step for a couple to consider if all the other problems
are corrected and still unsuccessful. Before beginning any of these procedures, urge a woman to
be in excellent health. The woman needs to undergo the following:
1. Discontinuing smoking or recreational drug behaviors
2. High protein in the diet.
3. Maintain BMI within normal range.
4. Undergo tests for HIV and hepatitis C
5. Hormone profiling including levels FSH, LH, estrogen, and progesterone.
6. Intravaginal sonogram to visual usual structures.
A. Alternative Insemination
Intrauterine Insemination is the instillation of sperm form a masturbatory sample into the
female reproductive tract by means of a cannula to aid conception at the time of ovulation.
1. The sperm can either be instilled into the cervix (intracervical insemination) or directly into
the uterus (IUI) at the time of predicted ovulation.
2. Ovulation is predicted by BBT charting, mucus analysis, or urinary test kits for LH can be
used to detect the day of ovulation.
3. Either the male partner’s sperm (alternative insemination by male partner) or donor sperm
(alternative insemination by donor can be used.
4. The indications for this procedure are:
- If the male partner has no sperm or inadequate sperm count
- If a woman has a vaginal or cervical factor has interfere with sperm motility, or a woman
has hormonal issues affecting fertility.
- The male partner has a known genetic disorder he does not want to be transmitted to
children or the woman does not have a male partner (Donor insemination can be
 used)
- The male partner who underwent vasectomy, chemotherapy, or radiation but now wish
to have children (Sperm can be frozen in a sperm bank before treatment/surgery)
5. The woman receives an injection of clomiphene (Clomid) or FSH 1 month prior to the
insemination to stimulate ovulation.
6. On a selected day of insemination, the sperm sample is instilled next to her cervix using a
device similar to a cervical cap or diaphragm, or sperm are injected directly into the
uterus using a flexible catheter (Fig. 3)

Figure 3. Alternative insemination. (A) Sperm are deposited next to the cervix, or (B) injected directly into the
uterine cavity.

7. Because conception through this procedure takes an average of 6 months or longer,

the couple needs to wait and maybe discouraged therefore need support to continue
the technique.
B. In Vitro Fertilization
In vitro fertilization is most often indicated for the for the following:
- The woman has obstructed or damaged fallopian tubes.
- The man has oligospermia or a very low sperm count.
- The woman has cervical problems which prevents the sperm to enter the cervix.
- The woman has antisperm antibodies causing immobilization of sperm.
 - Unexplained subfertility of long duration.

1. The woman is given FSH to stimulate oocyte growth, the ovaries are examined daily by
sonography. When follicles appear to be mature, a woman is given an injection of hCG,
which causes ovulation in 38 to 42 hours.
2. Mature oocytes are removed from a woman’s ovary (3 to 12 can be removed)
by laparoscopy and fertilized by exposure to sperm in a laboratory.
3. After 40 hours of fertilization, the fertilized ova (now zygotes) are inserted into a woman’s
uterus, where one or more of them will implant and grow (Fig. 4)

Figure 4. Steps involved in in vitro fertilization. (A) Ovulation. (B) Capture of ova (intra-abdominally). (C)
Fertilization of ova and growth in culture medium. (D) insertion of fertilized ova not uterus.

4. Progesterone or LH may be prescribed to a woman to support implantation.

5. If the couple desires, any eggs that are not used can be cryopreserved for use at a later
time.
6. A few women develop a n ovarian hyperstimulation syndrome with IVF. Their ovaries
become swollen and painful and they may have accumulating abdominal and lung fluid.
Women need to report these symptoms so ovarian stimulation can be halted until ovaries
return to normal.
Gamete Intrafallopian and Zygote Intrafallopian Transfer
7. In gamete intrafallopian transfer (GIFT) procedures, ova are obtained from ovaries exactly
as in IVF. Instead of waiting for fertilization to occur in the laboratory, both ova and sperm
are instilled, within a matter of hours, using a laparoscopic technique into the open end of a
patent fallopian tube. Fertilization then occurs in the tube, and the zygote moves to the
 uterus for implantation. It requires at least one paten fallopian tube; it may be preferred by
some couples because is it not contradictory to their religious beliefs.
8. Zygote intrafallopian transfer (ZIFT) is similar to IVF in that the egg is fertilized in the
laboratory, but like GIFT, the fertilized egg is transferred by laparoscopic technique into the
end of a waiting fallopian tube. Although available, this technique is little used today
because of the extensive laparoscopic technique needed.
C. Surrogate Embryo Transfer
Surrogate embryo transfer is an assisted reproductive technique for a woman who does not
ovulate. The process involves use of an oocyte that has been donated by a friend or relative or
provided by an anonymous donor. The menstrual cycles of the donor and recipient are
synchronized by administration of gonadotropic hormones. At the time of ovulation, the
donor’s ovum is removed by a transvaginal, ultrasound-guided procedure. The oocyte is then
fertilized in the laboratory by the recipient woman’s male partner’s sperm (or donor sperm)
and placed in the recipient woman’s uterus by embryonic transfer. Once pregnancy occurs, it
progresses the same as an unassisted pregnancy.
D. Preimplantation Genetic Diagnosis
The individual retrieval of oocytes and their fertilization under laboratory conditions have led to
close inspection and recognition of differences in sperm and oocytes. After the oocytes are
fertilized in IVF and ZIFT procedures, the DNA of both sperm and oocytes can be examined for
specific genetic abnormalities or specific genes such as Down’s syndrome or hemophilia.
Couples participating in intrauterine transfer and alternative insemination can also have the sex
of their children predetermined using these methods. Such techniques can be useful, because
popular methods to influence the sex of a child (such as douching with a baking soda mixture
before coitus to have a boy or with a vinegar solution to have a girl) have proved to be more
folklore than scientific fact. Allowing couples to choose the sex of children has ethical concerns
because it could result in skewed male/female ratios if used by a majority of couples.
VI. ALTERNATIVES TO CHILDBIRTH
For some couples, even treatments for subfertility with procedures such as IVF are not
successful. These couples need to consider still other options.
A. Surrogate Mothers

A surrogate mother is a woman who agrees to carry a pregnancy to term for a subfertile couple
or an LGBT couple. The surrogate may provide the ova and be impregnated by the man’s
sperm. In other instances, the ova and sperm both may be donated by the subfertile couple, or
donor ova and sperm may be used. Surrogate mothers are often friends or family members
who assume the role out of friendship or compassion, or they can be referred to the couple
through an agency or attorney and receive monetary reimbursement for their expenses. The
subfertile couple can enjoy the pregnancy as they watch it progress in the surrogate.
A number of ethical and legal problems arise if the surrogate mother decides at the end of
pregnancy that she has formed an attachment to the fetus and wants to keep the baby despite
the prepregnancy agreement she signed. Court decisions have been split on whether the
surrogate or the subfertile couple has the right to the child. Another potential problem occurs if
the child is born imperfect and the subfertile couple then no longer want the child. Who should
have responsibility in this instance? For these reasons, the couple and the surrogate mother
must be certain they have given adequate thought to the process, and to what will be the
outcome should these problems occur, before they attempt surrogate mothering.
B. Adoption
Adoption is an alternative to:
- Subfertile and LGBT couples
- Individuals who have genetic-related health conditions
- Individuals who have health conditions that would make pregnancy high risk
C. Child-Free Living
Child-free living is an alternative lifestyle available to both fertile and subfertile couples. For
many subfertile couples who have been through the rigors and frustrations of subfertility
testing and unsuccessful treatment regimens, child-free living may emerge as the option they
finally wish to pursue. A couple in the midst of fertility testing may begin to reexamine their
motives for pursuing pregnancy and may decide that pregnancy and parenting are not worth
the emotional or financial cost of future treatments. They may decide that the additional stress
 of going through an adoption is not for them, or they may simply decide that children are not
necessary for them to complete their family unit. For these couples, child-free living is a positive
choice.
Child-free living can be as fulfilling as having children, because it allows a couple more time to
help other people and to contribute to society through personal accomplishments. It has
advantages for a couple in that it allows time for both members to pursue careers. They can
travel more or have more time to pursue hobbies or continue their education. If a couple still

wishes to include children in their lives in some way, many opportunities are available to do this
through family connections (most parents welcome offers from siblings or other family
members to share in childrearing), through volunteer organizations or through local schools
and town recreational programs.
Many couples who believe that overpopulation is a major concern choose child-free living even
if subfertility is not present. Parents who choose child-free living typically rate their marriage as
happier than those with children, probably because of decreased expenses involved and more
free time that allows them to follow their hearts.
VII. Nursing Process
A. Assessment
Subfertility assessment used to require many months and many tests, all of which had the
potential to interfere with a couple’s self-image and self-esteem. Today, a subfertility
investigation is usually limited to three assessments: semen analysis, ovulation monitoring,
and tubal patency. Even with this more sensible approach to evaluation, nursing assessment
often reveals that one or both partners feel inadequate or angry and frustrated by what has
happened to them and the need to undergo testing. Questions such as, “How do you feel
about what has happened?” or “How do you think your partner feels about not being able
to conceive?”
may be enough to encourage partners to express these concerns.
Talking with both partners together may be advantageous, because they may feel more
comfortable speaking about their problem together. It is important to spend some time
 alone with each client in case there is anything a partner wishes to discuss privately. This
might be the only opportunity one of them has to ask that one “silly” question or voice a
fear that they believe is too foolish to ask or bring up in front of their partner.
B. Nursing Diagnosis
Nursing diagnoses related to subfertility are likely to focus on psychosocial issues associated
with the inability to conceive and the potentially nerve-wracking process of fertility testing
and management. Examples of possible diagnoses include:
1. Fear related to possible outcome of subfertility studies
Situational low self-esteem related to the apparent inability to conceive
1. Hopelessness related to perception of no viable alternatives to usual conception
If required tests interfere with a couple’s relationship (including sexual patterns).
“sexual dysfunction related to command performance of subfertility therapy” might be
applicable.
C. Expected Outcomes and Planning In
establishing expected outcomes with a couple undergoing fertility testing and counseling,
be certain that the couple realizes that results may not be instantaneous. A couple may
need to change or modify their goals if tests begin to show that what they first wanted—to
have a child without medical intervention—is impossible. Participation in a support group
may allow a couple to work through the stress that fertility testing places on their lives. It is
helpful to refer patients to online resources for further information and support.
D. Implementation
Fertility testing can be costly for a couple because not all health insurance programs provide
reimbursement for these procedures. Because of this, be certain couples are informed
beforehand of specific estimates of the cost of testing or therapy so they can budget and
plan their resources and the next steps they want taken.
Suggesting that a couple combine involvement with fertility testing with ongoing
activities or that they begin a new activity together (e.g., taking a night school course,
planting a garden, learning a new sport or hobby) at the same time they begin fertility
testing is a way of helping them reduce the feeling that their entire existence revolves
around the testing procedures. It also may help provide them with time for sharing
experiences and increasing intimacy, helping to compensate for any decreased enjoyment
that comes from “scheduled” sexual relations.
Throughout testing, couples need thorough education about the various procedures.
Make sure to review any specific instructions about preprocedural and postprocedural care.
Depending on their motivations, a couple’s reaction to study results may vary from relief to
stoic acceptance, to grief for children never to be born. Each partner may wonder whether
the other will be able to continue the relationship if he or she turns out to be the
“subfertile” one. Couples need the active support of health care personnel from the first
day they braced themselves to ask, “Exactly why are we childless?” until the end, regardless
of the results.
E. Outcome Evaluation
Examples of expected outcomes in this area include:
1. The patient rearranges work plans to manage schedule of fertility testing by 1
months’ time.
2. The couple verbalizes that they understand their individual subfertility problem after
preliminary testing.
3. The couple demonstrates a high level of self-esteem after fertility studies, even in
the face of disappointing study outcomes.
For the couple with the problem of subfertility, evaluation is best if it is ongoing because, as
circumstances around them change, so may their goals and desires. Until they can accept an
alternative method of having children—adoption or an assisted reproductive technique
such as alternative insemination or in vitro fertilization—former plans have been crushed.
Future evaluation is also important, because a couple who decides at age 20 to choose
child-free living may change their minds at a later date. A couple who chooses an assisted
reproductive technique may decide after several unsuccessful attempts that they are no
longer interested in this method of conception. Keeping evaluation an ongoing process
allows such plans to be modified as necessary. Encourage couples seen for subfertility to
call or visit their subfertility setting every 6 to 12 months to inquire about new discoveries in
the field and how these might apply to their situation
4. Anxiety related to what the process of fertility testing will entail
5. Deficient knowledge related to measures to promote fertility
6. Anticipatory grieving related to failure to conceive or sustain a pregnancy
7. Powerlessness related to repeated unsuccessful attempts at achieving conception