FAMILY HAVING DIFFICULTY CONCEIVING A CHILD:

09-22-2022
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KEY TERMS:
• Subfertility – is said to exist when a pregnancy has not occurred after at least 1 year of engaging
in unprotected coitus (Hamilton, 2012)
• Primary subfertility – there have been no previous conceptions; in secondary subfertility, there
has been a previous viable pregnancy but the couple is unable to conceive at present.
• Sterility – is the inability to conceive because of a known condition, such as the absence of a
uterus.
• Infertility – inability to conceive a child or sustain a pregnancy to birth
• Infertile couple – one who has not become pregnant after at least 1 year of unprotected coitus

Male Subfertility Factors:

• Disturbance in spermatogenesis; inadequate FSH and LH production
• Seminiferous tubule, duct, or vessel obstruction; seminal fluid changes prevent sperm motility
• Development of autoimmunity; ejaculation problems
• Chronic or excessive exposure to X-rays or radioactive substances, general ill health, poor diet,
and stress

Female Subfertility Factors:

• Inadequate FSH or LH production
• Anovulation
• Problems of ova transport through the fallopian tubes to the uterus
• Uterine factors
• Cervical and vaginal factors
• Poor nutrition, increased body weight, lack of exercise

Fertility Assessment:
• Health history (both partners)
• General health
• Nutrition
 • Alcohol, drug, or tobacco use
• Congenital problems of reproductive tract, past STDs or genital tract surgery
• Current illnesses
• Contraceptive history and pregnancies in previous relationships
• Occupational/lifestyle hazards

• Health history (female partner)

• Past pregnancies, miscarriages, abortions
• Menstrual history
• Current or past reproductive tract problems
• Radiation to pelvis (cancer treatment, occupational exposure, diagnostic X-rays)
• Use of douches or intravaginal medications or sprays
• Detection of ovulation through symptomatology
• Female circumcision

Fertility Assessment: Physical Assessment:

• Male partner:
• Secondary sex characteristics
• Genital abnormalities
• Female partner:
• Secondary sex characteristics
• Genital abnormalities
• Breast and thyroid examination

Fertility Testing: Answering the Three Basic Questions:

• Is there sperm of good quality, number, and motility available?
• Semen analysis
• Are ova available?
• Ovulation monitoring
• Can sperm and ovum meet in a receptive environment?
• Assessment of fallopian tube patency
Fertility Testing: Ovulation Monitoring:
• Ovulation monitoring:
• Measurement of woman’s serum progesterone level during luteal phase of menstrual cycle
• Recording of basal body temperature
• Measurement of urine LH upsurge (urine test strip)

Fertility Testing: Tubal Transport (Tubal Patency):

• Sonohysterosalpingogram
• Hysterosalpingogram
• Transvaginal hyrdolaparoscopy

Fertility Testing: Uterine Concerns:

• Hysteroscopy
• Uterine endometrial biopsy
• Laparoscopy

ASSISTED REPRODUCTIVE TECHNIQUE:

Definition: WHO
• Infertility – inability to conceive after more than one year of intercourse without contraception
• It can be both male and female

Causes of infertility:
In male:
• Sperm production/ sperm count disorder
• Azoospermia – no sperm cell produced
• Oligospermia – few sperm cell produced
• Erectile or ejaculation deficiency – failure of impotence
• Structural abnormalities – shaper or motility of the sperm is affected preventing the sperm from
 either swimming to or binding with the egg.
• Age – aged male has less sperm count and motility rate.

In female:
• Ovulation disorders – PCOS (polycystic ovarian syndrome)
• Tubal blockage – prevents ovum and sperm meeting.
• Advanced maternal age – quality of woman’s ovum decrease with age and can limit her ability
to conceive.
• Quality of uterine lining – e.g., endometriosis, in which womb tissues invades and damages
neighboring reproductive tissues.

ARTIFICIAL REPRODUCTIVE TECHNOLOGY:

• Defined as the technology to achieve pregnancy by means of procedures.

• Artificial insemination
• In vitro fertilization
• Surrogacy

• Artificial Insemination:
• Introduction of sperm into the female’s uterus or cervix for the purpose of achieving pregnancy
through in vitro fertilization other than sexual intercourse.

Types of artificial insemination:

• Intracervical
• Intrauterine
• Intratubal

• Intratubal Insemination:
• It involves injection of the washed sperm into the fallopian tube.
• It should not be confused with the GIFT, where both the eggs are mixed outside the women’s
body and then immediately inserted into fallopian tube.
• Less used than IUI
 • Intracervical Insemination:
• It involves injection of unwashed or raw semen into the cervix with the needleless
syringe.
• A vaginal speculum is used to hold open the vagina so that cervix may be observed and
then syringe is inserted, the plunger is pushed forward and semen is emptied deep in the
vagina.

• Intrauterine Insemination:
• The seminal vesicle is prepare in the laboratory (washed with special media). Injected
inside the uterus with catheter after stimulating the ovaries to produce more eggs per
cycle.
• The catheter used here is known as ‘TOM CAT’

• In Vitro Fertilization:
• The uniting of egg and sperm in the lab. The embryos are transferred into the uterus through the
cervix and pregnancy will begin.
• Letting fertilization of male and female gametes occur outside the female body.

Steps of In Vitro Fertilization:

• There are generally five major steps in the process of IVF.

• Ovary stimulation
• Oocyte retrieval
• Sperm retrieval-wash sperm
• Fertilization
• Embryo transfer

Ovary stimulation:
• Different hormones are given to female in order to stimulate formation of more than one ovum.
• Formation of more than one ovum for multiple zygote or embryos to increase the probability for
getting a healthy embryo
 • Drugs or hormone like Clomiphene (clomid), hMG (pergonal), FSH (metrodin), GnRH agonists
(Lupron) – FSH-LH first promoted, then inhibited hCG-acts like LH

Oocyte retrieval:
• Technique used to remove oocyte from the ovary of the female to have fertilization outside the
body.
Procedure:
• With the ultrasound guidance a needle is inserted into the vaginal wall and into the ovarian
follicle, taking care not to injure organs located between the vaginal wall and the ovary.
• The other end of the needle is attached to the suction device
• Then the follicular fluid and cellular material is suctioned with the needle
• The procedure will last 10 – 20 minutes

Sperm retrieval:
• Three hour before the procedure, a semen sample from the male donor is obtained.
• The sperm is washed and prepared for loading into the same catheter together with the females
best eggs.
• The eggs are obtained by transvaginal aspiration/ultrasound.

Fertilization:
• After retrieval of sperm and egg, they are brought together in a laboratory glass dish to allow the
sperm to fertilize the eggs, called standard insemination. Once fertilization takes place one or
more healthy embryo will be transferred to the uterus.

GAMETE INTRA FALLOPIAN TRANSFER (GIFT):

• It is a tool of assisted reproductive technology against infertility. Eggs are removed from a
woman’s ovaries, and placed in one of fallopian tubes, along with the man’s sperm.
• The first attempt was made by Steptoe and Edwards
• It takes on average four to six weeks to complete the cycle of GIFT

Advantages:
• There is no much human intervention in the actual fertilization of the eggs.
 • Because fertilization takes place within the fallopian tube, GIFT offers an option for people
whose religious beliefs prohibit conception outside the body.

Disadvantages:
• Can be performed only if woman have at least one normal fallopian tube
• GIFT does not allow for visual confirmation of fertilization.
• GIFT involves a laparoscopic surgery

ZYGOTE INTRAFALLOPIAN TRANSFER (ZIFT):

• It is an infertility treatment used when a blockage in the fallopian tubes prevents the normal
binding of sperm to the egg.
• Egg cells are removed from a woman’s ovaries, and in vitro fertilized. The resulting zygote is
placed into the fallopian tube by the use of laparoscopy.
• It has the success rate of 64.8% in all the cases.

Advantages:
• Fertilization can be confirmed before they are implanted into the fallopian tube.
• Allows a developing embryo to travel into the uterus on its own, which may be important to those
who wish their baby to develop as naturally as possible.

Disadvantages:
• Can be performed only if woman have at least one normal fallopian tube.
• It is more expensive than GIFT.
• ZIFT involves laparoscopic surgery.

INTRA CYTOPLASMIC SPERM INJECTION (ICSI):

• Sperm is injected directly into eggs in a laboratory.
• Used if infertility originates from the male such as:
• Low numbers of sperm
• Low sperm motility
 • Single spermatozoan is directly injected into the cytoplasm of the oocyte through the
micropuncture of zona pellucida

Advantages:
• Can be useful when very low numbers of motile sperm are present and when there are problems
with sperm binding and penetration.

Disadvantages:
• Altering the nature’s selection process for sperm can lead to an increase risk of developmental
and health issues for ICSI children, as well as a higher risk of miscarriage because of the poorer
genetic material involved.

TUBAL EMBRYO STAGE TRANSFER (TET):

• It combines IVF with tubal transfer
• Embryos are placed into the women’s fallopian tube.
• The embryos are transferred back into the woman 2 days after fertilization. This is at the ‘2 cell or
4 cell’ stage.
• TET allows embryos to make their way to the uterus for implantation.
• Its advantage over ZIFT is that allows for the assessment of fertilization and embryo quality.
• Success rate higher than ZIFT.

• Surrogacy:
• Surrogacy is when another woman carries and gives birth to a baby for the couple who want to
have a child.
• It is the carrying of pregnancy for intended parents.
• In this a woman agrees to became pregnant and deliver a child for a contracted party.

Types:
• Traditional surrogacy – it is the simplest and least expensive for surrogacy and is also known as
artificial insemination. The surrogate mother uses and insemination kit to became pregnant using
an intended father’s semen.
• Gestational surrogacy – it is physically more complicated and more expensive. Here both the
eggs and sperm are taken from intended father and mother.
NEGATIVE ASPECT OF ART:
• Due to administration of hormones and drugs, ovarian hyperstimulation syndrome (OHSS) can
occur.
• Risks associated with pregnancy
• Multiple pregnancy
• Increased risk premature labor etc.
• Can cause premature menopause.
• Increased risk of ovarian cancer, at least by 3 time when compared to normal women.

RECENT TRENDS:
• Innovative design of IVF equipment (PLoS ONE, June 2012)
• A novel system for processing embryos during IVF treatment has been shown to significantly
improve the chances of pregnancy by 27%.
• Pioneered by a Newcastle team of fertility experts within the University and NHS, the innovative
design of interlinked incubators provides a totally enclosed and controlled environment within
which every step of the IVF process can be performed.

CONCLUSION:
• ART has been the answer for many childless couples, resulting in successful pregnancies and
childbirth.
• Today there is a range of infertile treatment that aims to ensure a healthy sustainable pregnancy.
• But there are still risks, stress and high cost associated with ART.
• With the advent of new technologies, it is hoped that these shortcomings would be overcome in
the near future and every infertile couple would have the privilege of parenthood.

SELF-CHECK:
• A woman calls into the ambulatory care center. She reports that her at-home ovulation predictor
test strip results were “positive.” She asks what this means. Which should the nurse explain?
A. “The kit has detected an increased presence of luteinizing hormone (LH) in the urine.”
B..“The kit has determined that your cervical mucus is receptive to sperm.”
 C. .“The kit has detected an increase in free estrogen in the urine.”
D. .“The kit has detected that ovulation will take place within the next 6 to 8 days.”

Rationale: The kit has detected in the urine the hormone that surges prior to ovulation, indicating that the
woman is approaching ovulation. Usually, a positive test will indicate that an ovum will be released
within the next few days, indicating the most fertile period during the menstrual cycle. The kit does not
test for presence of estrogen in the urine or the condition of the cervical mucus.
• A woman is using a basal body temperature (BBT) graph to monitor fertile periods. She calls to
report that she did not see any temperature change during her past monthly cycle. To which does
the nurse attribute this?
• An elevated estrogen level
• An elevated FSH level
• A failure to ovulate
• An elevated progesterone level

Rationale: The most likely reason is that the woman probably did not ovulate during this menstrual
cycle. During a cycle when ovulation occurs, FSH and estrogen increase near the time of ovulation and
progesterone surges within several days after ovulation.

• In counseling a couple who have experienced subfertility for 14 months, which of the following
true statement does the nurse base the initial information given to them?
• Transrectal and scrotal ultrasound testing is routinely performed in the male.
• Semen analysis is usually not performed until all tests in the female partner are negative
• Testing for tubal patency is performed during the same time period as ovulation monitoring is
being done.
• Fertility testing usually begins with ovulation monitoring in the woman.
Rationale: ovulation monitoring in the woman and semen analysis in the man are usually the first steps
taken in fertility testing because these are the least invasive of procedures and answers two of three basic
questions related to subfertility (sperm quality and available ova). Transrectal and scrotal ultrasound and
checking for tubal patency are more invasive procedures and are performed if these initial tests are
negative.