TOPIC: NURSING CARE OF FAMILY HAVING DIFFICULTY CONCEIVING A CHILD
-30% normal in shape and form
Infertily- inability to conceive a child or sustain a pregnancy to birth
Infertile-not become pregnant after atleast 1 year of unprotected sex
Subfertility- have potential to conceive but are just less able to conceive w/o
additional help.
ASSESSMENT
Subfertility assessment-require many months and tests
Three assessments are semen analysis, ovulation monitoring, and tubal
patency
NI: talking with both partners together may be advantageous bcs they may
feel more comfortable speaking abt their problem together.Spend some time
alone with each pt in case there is anything a partner wishes wishes to
discuss privately.
IMPLEMENTATION
NI: combine involvement with fertility testing testing with ongoing ctivities or
beginning new activities- a way of helping them to reduce the feeling that
their entire existence revolves around the testing procedure
Artificial insemination- deposition of sperm in to a cervikx or uterus
IVF-union of sperm and ovum under lab conditions
SUBFERTILITY
- Exist when a pregnancy has not occurred after at least 1 year of
unprotected sex
- Extended period of unwanted nonconception
Primary subfertility- no prev conception
Secondary subfertility- has been prev viable pregnancy but there is inability
to conceive at present
Sterility- inability to conceive because of a known con
Couples who engage in coitus ,hoping to cause early impregnation , may
actually have more difficulty conceiving than those who space coitus every
other day. Too frequent coitus can lower sperm count to a level below
optimal fertility
Age is related to subfertility
30s have more difficulty conceiving than their younger counterpart
FERTILITY ASSESSMENT
Fertility testing not before age 18 yo and not after age 45 years
Test should after 1 year of subfertility- younger than 35 yo
Test should after 6mos- 35 yo or older
Eat a diet high in slowly digested carbs, low in sat and trans fat, and
moderate in protein .Exercise 30 mins per day
PHYSICAL ASSESSMENT
Varicocele- enlargement of testicular vein
Hydrocele – collection of fluid in the tunica vaginalis of the scrotum rarely
associated with subfertility but should be documented if present
FERTILITY TESTING
Three test: semen analysis (male), ovulation monitoring and tubal patency
(female), meeting of sperm and ova
FACTORS THAT CAUSE MALE SUBFERTILITY
-Disturbance in spermatogenesis (production of sperm cells)
-inadequate production of FSH and LH
-Obstruction in the seminiferous tubules,ducts, or vessels
-Qualitative and quantitative changes in the seminal fluid prevents sperm
motility (movement of sperm)
-development of autoimmunity
-problems in ejaculation and deposition
-chronic exposure to x-ray or radioactive subs
LIMITED SPERM COUNT
Sperm count- number of sperm in a single ejaculation or in ml of semen
-33 to 46m sperm per ml of seminal fluid, 50m per ejaculation
-50% of sperm are motile
Spermatozoa prod and maintained at temp slightly lower than body temp to
be fully motile.Testes, which sperm are produced and stored are suspended
in the scrotal sac away from body heat
Chronic infection from tuberculosis or recurrent sinusitis lower sperm
count.ALSO congenital abnormalities such as crytochordism – undesended
testes
Varicole or varicosity- enalargemment of internal spermatic vein, increase
temp and congestion w/in testes, slow and disrupt spermatogenesis.Surgical
removal of varicocele may dec warmth and improve fertility in some
NI: When assisting with pelvic x-rays, be certain biologic males are furnished
a protective lead shield to guard against radiation to the testtes
TESTING OF SPERM NUMBER AND AVAILABILITY
Semen analysis and sperm motility- identify wether adequate sperm are
present
ANALYSIS OF PITUITARY HORMONES
Blood test and analysis- determine wether adequate levels of FSH and LH are
present.
When secondary male sex features are present limited sperm count is rarely
a problem
SEMEN ANALYSIS
1.4 to 1.7 ml semen contain 33 to 46m spermatozoa per ml of fluid
SA steps: abstinent 2 to 4 days prior to analysis, ejaculates by masturbation
into clean dry specimen jar, examined under microscope within 1 hour of
ejaculation
Analysis need to be repeated after 2 to 3 mos bcs spermatogenesis is an
ongoing process and 30 to 90 days is needed for new sperm to reach out
maturity
If pt has vasdeference obstruction ,sperm can be obtained by testes biopsy
SPERM PENETRATION ASSSAY AND ANTISPERM ANTIBODY TESTING
Sperm must be mobile enpugh to navigate the vagina, uterus, and fallopian
tube to reach the ova
Intracytoplasmic sperm injection- assisted repro technique,poorly mobile
sperm with poor penetration can be injected directly to ovum under lab con
THERAPY FOR INCREASING SPERM COUNT AND MOTILITY
NI: if sperm are present but total count is low , advised to abstain from coitus
for 7 to 10 days at a time to increase count. Ligation of varicocele, avoiding
cannabis, thight clothing long periods of stting and hot baths reduce scrotal
heat and increase sperm count
OBSTRUCTION OR IMPARED SPERM MOTILITY
Diseases such as : mumps orchitis (testicular inflammation and scarring due
to to the mumps virus), epididymitis (inflammation of epididymis) and
infections such gonorrhea and escending urethral infection- since adhesions
form and occlude sperm transport
Benign hypertrophy of prostate gland- occurs at 50 yo. Pressure from
enlarged gland on vas deference I terfere with sperm ytransport. A condition
in men in which the prostate gland is enlarged and not cancerous.
Vasectomies dev an autoimmune reaction or form antibodiesnthat
immobilizes their own sperm after procedurethat immobilizes sperm
Diseases such as: hypospadias( urethral opening on ventral surface of penis),
epispadias (urethral opening of dorsal surface of penis.), Peyronie disease ( a
bent penis, a condition in which fibrous scar tissue forms in the deeper
tissues under the skin of the penis. This causes curved, painful erections. It
also can make the penis shorter while erect. Peyronie disease is not caused
by cancer.) cause sperm deposited too far from sexual partners cervix to
allow optimal cervical penetration—interfere penetration and deposition
TESTING FOR SPERM TRANSPORT DISORDERS
- Suspected when FSH and LH hormones, stimulate prod of sperm,
are adequate but sperm count remains limited

THERAPY FOR SPERM TRANSPORT DISORDERS
NI: extracting sperm from a point above the blockage and injecting it into
vagina or uterus by intrauterine insemination
Abstinence or condom used for 6 mos must be reduced if sperm are
immobilize by vaginal secretions due to immunologic factor
Admistration of corticosteroid to female may effect in sperm immobilization
bsc it reduces immune response and antibody prod
EJACULATION PROBLEMS
Erictile dysfunction- inability achieve erection or called impotence, occur
from psychological problems and disease such as CVA, diabetes, parkinsons,
use of antihypertensive drugs, discontinuation of finasteride ( for male
pattern baldness, treats BPH by blocking the body's production of a male
hormone that causes the prostate to enlarge. Finasteride treats male pattern
hair loss by blocking the body's production of a male hormone in the scalp
that stops hair growth.): primary –never been able to achieve erection,
secondary was able to achieve erection in past but now has difficulty
THERAPY FOR EJACULATION CONCERNS
Sol for ED: psychological and sexual counseling, use of phosphidieterase
inhibitor such as sildenafil (Viagra) and tadalfil (Cialis)
Dapoxetine- short- acting selective serotonin reuptake inhibitor, for
premature ejaculation (occurs in men when semen leave the body (ejaculate)
sooner than wanted during sex) , good result when taker after 1 hour before
coitus
FACTORS THAT CAUSE FEMALE SUBFERTILITY
-limited prod of FSH and LH
-Anouvulation
-prob in ova transport
-uterine factors
-cervical and vaginal factors
-poor nutria, increase body weight, lack of exercise
ANOVULATION
- Absence of ovulation or release of ova from the ovary)
- Common cause is genetic abnormality such as turner syndrome
(hypogonadism, limited tissue avail to prod ova), hormonal
imbalances such as hypothrrodism and hyperprolactinemia
interfere with hypothalamus-pituitary-ovarian interaction, ovarian
tumors or pcos (ova prod excess testosterone which lower the
FSH and LH), excessive exposure to x-ray
- If glucose or insulin level is high they disrupt prod of LF and FSH
leading to ovu failure , should inatake slowly digested carbs and
fiber rich foods and exercising
- Stress limits ovu, lower hypothalamic secretions of GnRH WHICH
THE LOWER PROD OF fsh and lh
- Dec body weight of less than 10%reduce pituitary hormones
Vit D- maintains pituitary hormone levels
PCOS diagnosed with: Waist C- 35inch or more, FBG- 100mg/dl, Serum
triglyceride- 150 mg/dl, BP- 135/85mmHg, HDL cholesterol- 50mg/dl, dev of
hirsutism
OVULATION MONITORING
Fatest way to know if ovu is occurring is to measure serum progesterone
level durng luteal phase, if elevated , corpus leteum has formed and
ovulation has occurred
BBT- low cost, determine ovu patter, must record at least 4 mos,taken early
morning before getting out of bed, tympanic thermo should used
OVULATION DETERMINATION BY TEST STRIPS
OTS is hussle-free and otc, midmorning urine speci is needed, Ovulation test
strips or ovulation predictor kits (OPKs) are at-home tests you can use to
determine when you’re ovulating. Because you’re most fertile during
ovulation, the kits can help increase your chances for success when you’re
trying to conceive.
Ovulation test strips work by measuring levels of luteinizing hormone (LH) in
your urine. A rise in LH signals the ovary to release an egg — so when your
levels reach a certain threshold, it’s safe to assume that ovulation will occur
within the next 12 to 36 hours.
Pelvic sonogram- used to confirm cyst on ovaries in pcos
THERAPY FOR ANOVULATION
Administration Of GnRH used to stimulate fsh and lhif disturbance of
ovulation is identified
Clomiphene (citrate) or letrozole (femara)- used to stimulate ovu
Combinations of FSH and LH with HCG prod ovu
Bromocriptine (parlodel)- if increased prolactin levels,allows rise of GnRH
Administration of either clomiphene citrate and gonadotropins overstimulate
an ovary causing multiple ova to maturity and possible resulting in multiple
births
TUBAL TRANSPORT PROBLEMS
Difficulty with tubal transport usually occurs bcs scaring has dev in ft cause by
chronic salphingitis, ruptured appendic by abdominal surgery (since
infections might spread to ft and may left adhesions)
PID- infections of pelvic organs, usual source is STI such as chlamydia and
gonorrhea, avoid multiple sexual partners
TESTING FOR TUBAL PATENCY
Ultrasound or x-ray imaging and direct visualization by hysteroscope of ft
1. **Sonophysterosalpingogram (SPSG)**:
- This procedure combines transvaginal ultrasound (sonography) with the
injection of a saline solution into the uterus.
- The saline solution helps to outline the uterine cavity and fallopian tubes,
making them more visible on the ultrasound.
- It is primarily used to evaluate the anatomy of the uterus and fallopian
tubes and to diagnose conditions such as uterine abnormalities, tubal
blockages, and other causes of infertility.
2. **Hysterosalpingogram (HSG)**:
- Hysterosalpingogram is a radiologic procedure that uses X-rays to examine
the uterus and fallopian tubes.
- During an HSG, a contrast dye is injected through the cervix into the
uterus, and X-ray images are taken as the dye flows through the uterus and
fallopian tubes.
- This procedure helps to identify abnormalities in the uterine cavity, such
as polyps, fibroids, or scar tissue, as well as blockages or abnormalities in the
fallopian tubes.
- Like the sonophysterosalpingogram, HSG is often used to investigate
infertility or recurrent miscarriages.
3. **Transvaginal Hydrolaparoscopy (THL)**:
- Transvaginal hydrolaparoscopy is a minimally invasive surgical procedure
used to directly visualize the pelvic organs, including the uterus, fallopian
tubes, and ovaries.
- It involves inserting a thin, flexible telescope (laparoscope) into the pelvic
cavity through a small incision made in the vagina.
- Carbon dioxide gas or saline solution is used to inflate the pelvic cavity,
providing a clearer view of the organs.
- THL allows for a detailed examination of pelvic anatomy, assessment of
tubal patency, detection of endometriosis, and other pelvic pathologies.
- It is often performed as part of the evaluation for infertility or pelvic pain.
In summary, while sonophysterosalpingogram and hysterosalpingogram both
use imaging techniques to assess the uterus and fallopian tubes, they differ in
the type of imaging used (ultrasound vs. X-rays). Transvaginal
hydrolaparoscopy, on the other hand, is a surgical procedure that directly
visualizes the pelvic organs and is typically used for more detailed evaluation
of pelvic pathology.
THERAPY FOR LACK OF TUBAL PATENCY
1. **Diathermy**:
- Diathermy is a surgical technique that uses high-frequency electrical
currents to generate heat within tissues.
- In the context of tubal insufficiency, diathermy might be used to remove
scar tissue or adhesions that are blocking or impairing the function of the
fallopian tubes.
- By carefully targeting and removing the scar tissue, diathermy can
potentially restore the patency (openness) of the fallopian tubes, improving
fertility.
2. **Steroid Administration**:
- Steroids, such as corticosteroids, are anti-inflammatory medications that
can help reduce inflammation in the body.
- In cases where tubal insufficiency is caused by inflammation, such as in
pelvic inflammatory disease (PID), steroid administration might be used as
part of the treatment regimen to reduce inflammation in the fallopian tubes.
- By reducing inflammation, steroids may help alleviate symptoms and
prevent further damage to the fallopian tubes, potentially improving their
function.
3. **Canalization of Fallopian Tube**:
- Canalization refers to the process of creating or restoring a canal or
passage within a structure.
- In the context of tubal insufficiency, canalization of the fallopian tubes
involves procedures aimed at opening or creating a passage within blocked
or narrowed portions of the tubes.
- Techniques for canalization may include using specialized instruments,
such as catheters or microsurgical instruments, to mechanically open the
fallopian tubes or remove obstructions.
4. **Plastic Surgical Repairs (microsurgery)**:
- Plastic surgical repairs involve the reconstruction or repair of damaged
tissues using surgical techniques.
- In the context of tubal insufficiency, plastic surgical repairs may be
performed to reconstruct or repair the fallopian tubes, particularly if they
have been damaged by inflammation, infection, or trauma.
- Surgical repair techniques may involve removing scar tissue, reconnecting
severed portions of the tubes, or reinforcing weakened areas to improve
tubal function.
5. Hysterosalpinogography- instillation of contrats dye under x-ray
monitoring to see dye insertion will break adhesions
6.Laparascopy- if peritoneal adhesions or nodules of endometriosis are
holding the tubes
FT tubes that has been ligated, reopening success is not more than 70 or
80%, can result in ectopic pregnancy
UTERINE CONCERNS
Fibromas (leiomyomas or fibroids)- rare cause of subfertility if they block the
entrance of ft into uterus for effective implantation
Endometriosis (implantation tissue similar to the uterine endometrium in loc
outside uterus. Most common sites are ft, cul-de-sac of douglass,ovaries,
uterine ligaments, outer surface of uterus and bowel) and poor excretion of
estrogen and progesterone common uterine reasons for subfertility
Peritoneal macrophages – drawn to endometriosis implants, can destroy
sperm
TESTING FOR UTERINE CONCERNS
Sonogram or hysteroscopy to view sstructur of uterus, blood work to analyze
hormones such as endometrial biopsy
HYSTEROSCOPY
- Visual inspection of uterus through insertion of hysteroscope (thin
hallow tube attached to a cam) evaluate uterine adhesions,
malformations, abnormalities such as fibroid tumors or polyps.
NI:screened for sti before examination to prevent introd of bac in
uterus
UTERINE ENDOMETRIAL BIOPSY
- Reveal endometrial prob, if samples is removed a corkscrew
(typical progesterone0 dominated endometrium) seen in 2nd halg
of mens cycle suggest ovu has occurred
- Done 2 to 3 days before expected men flow
- Pt may exper mild-to-moderate discomfort from maneuvering
instrument
- Moment of sharp pain as specimen is taken
- Possible compli : pain, excessive bleeding, infection, uterine
peroration
- Contraindicated in pregnancy is suspected
- NI: if pt has infection such as PID and cervicitis, vaution pt that a
small amt of vaginal spotting may noticed after proced
Paracervical block- local anaesthetic used during 1st stage of labor to dec pain
associated with cervical dilation and uterine cramping
LAPARASCOPY
- Introd of thin hallowed lighted tubethru small incision in abdomen
under umbilicus to examine position and state of Ft and ovaries
- Done in result of uterosalpingography is abnormal bcs pain is is
extensive caused by maneuvering ,requires gen anesthesia
- Scheduled during follicular phase and mens cycle
- NI: pt positioned steep trendelenburg
- CO2- introd in abdomen to kove abdominal wall outward to offer
better visualization, may feel bloated .If escapeunder
diaphragm,feel extremely sharp shoulder pain from pressure of
gas and cervical nerves
- Contrast medium is injected in uterus thru polyethylene cannula
placed in cervixto assess tubal patency
-
THERAPY FOR UTERINE CONCERNS
Progesterone vaginal suppositories- if prob of fertility appears in luteal
phase, 3rd of pt temp rise and continued for next 6 weeksor until mens flow
begins
Myoma (fibroid tumor)- intrauterine adhesions interferes with fertility
Myomectomy- surgical removal of tumor and adhesion fr myoma
Hysteriscopic amubulatory proced- for small growth fr myoma
Endometriosis can be treated surgically
VAGINAL AND CERVICAL CONCERNS
If cervical muscus is thin and watery can be penetrated by sperm for 12 to 72
hrs
Infection of inflammation can cause cervical mucus to thicken
Stenotic cervical os (obstruction of os by polyp)- compromise sperm
penetration, sole cause of subfertility
Infection of vagina cause ph level bcm acidotic ,destrying motility od sperm
Sperm-immobilizing and sperm-agglutinating antibodies in plasma destroys
sperm
TESTING ANG THERAPY FOR VAGINAL AND CERVICAL CONCERNS
Low-dose estrogen therapy such as conjugated estrogen (premarin)- if sperm
not survive in vaginal secretions, increase mucus prod during days 5 to 10 of
cycle
Vaginals infections such as tricomoniasis and moniliasis can recur
NI: caution pt take metronidazole (flagyly) for tricomonas infec, no study
shows fetal mal, it may teratogenic early in preg,not con if preg is suspected
ASSISTED REPRODUCTIVE TECHNIQUES
AR strategies-if ovu, sperm prod, sperm mobility prob can’t be corrected
Anti-mullerian (amh)- test for ovarian reserves (wether ova have capacity to
prod multiple oocytes
ALTERNATIVE INSEMINATION
traditional methods have not been successful. Here's an overview of some
common ART procedures, along with their differences and functions:

1. **Alternative Insemination**:
- Alternative insemination, also known as artificial insemination or
intrauterine insemination (IUI), involves placing sperm directly into the
uterus around the time of ovulation.
- This procedure can be performed with sperm from a partner or a donor.
- Alternative insemination is often used in cases of unexplained infertility,
mild male factor infertility, or when cervical factors impede sperm from
reaching the egg naturally.
- It is a less invasive and less costly option compared to other ART
procedures.
Intracevical insemination- sperm instilled into cervix
Intrauterine insemination- directly in uterus
Male partners sperm- alternative insemination by male partner
Donor sperm-AI by donor
Cryopreserved- frozen in sepm bank before radiation or chemotheraphy
(disadvantage: slower motility but no incidence of congenital anomalies)
Clomiphene (clomid) or fsh- injection, 1 mos prior to insemination so follicle
growth of ova is stimulated
IF FSH USED TO STIMULATE FOLLCLE GROWTH THERE IS A CHANCE POF
MULTIPLE BIRTH
2. **In Vitro Fertilization (IVF)**:
- In vitro fertilization involves the fertilization of an egg with sperm outside
the body, typically in a laboratory dish.
- After fertilization occurs and embryos develop, one or more embryos are
transferred into the uterus.
- IVF is used to treat a variety of infertility issues, including tubal blockages,
male factor infertility, endometriosis, and unexplained infertility.
- It is one of the most commonly used and successful ART procedures.
3. **Gamete Intrafallopian Transfer (GIFT)**:
- Gamete intrafallopian transfer involves the transfer of eggs and sperm
into the fallopian tubes, where fertilization can occur naturally.
- This procedure is less common than IVF and is typically used when the
fallopian tubes are healthy and functioning correctly but other factors
prevent conception.
- GIFT requires laparoscopic surgery to transfer the gametes into the
fallopian tubes.
4. **Zygote Intrafallopian Transfer (ZIFT)**:
- Zygote intrafallopian transfer involves transferring fertilized embryos
(zygotes) into the fallopian tubes.
- Like GIFT, ZIFT requires laparoscopic surgery and is less commonly
performed compared to IVF.
- ZIFT may be recommended when IVF has failed or when there is a need
for early embryo selection.
5. **Surrogate Embryo Transfer**:
- Surrogate embryo transfer, also known as gestational surrogacy, involves
transferring embryos created through IVF into the uterus of a surrogate
mother who carries the pregnancy to term.
- This procedure is used when a woman is unable to carry a pregnancy
herself due to medical reasons, such as uterine abnormalities or recurrent
pregnancy loss.
6. **Preimplantation Genetic Diagnosis (PGD)**:
- Preimplantation genetic diagnosis involves testing embryos created
through IVF for genetic disorders or chromosomal abnormalities before they
are transferred to the uterus.
- PGD allows for the selection of embryos that are free of genetic
conditions, reducing the risk of passing on inherited diseases to offspring.
7. **Uterus Transplantation**:
- Uterus transplantation involves transplanting a uterus from a donor into a
woman who does not have a functioning uterus.
- This procedure is still considered experimental and is primarily used in
cases of absolute uterine factor infertility, such as in women who were born
without a uterus or had it removed due to medical reasons.
ALTERNATIVES TO CHILDBIRTH
1. **Surrogacy**:
- Surrogacy involves a woman (the surrogate) carrying and delivering a child
for another individual or couple (the intended parents).
- There are two main types of surrogacy: traditional surrogacy and
gestational surrogacy. In traditional surrogacy, the surrogate's own eggs are
used, making her genetically related to the child. In gestational surrogacy, the
embryo is created using the intended mother's or a donor's egg and the
intended father's sperm, so the surrogate has no genetic relationship to the
child.
- Surrogacy is typically pursued by individuals or couples who are unable to
carry a pregnancy themselves due to medical reasons, such as infertility,
recurrent pregnancy loss, or medical conditions that make pregnancy
dangerous.
- Surrogacy allows individuals or couples to have a biological connection to
their child while still experiencing the joys of parenthood.
2. **Adoption**:
- Adoption involves legally and permanently assuming parental rights and
responsibilities for a child who is not biologically related to the adoptive
parents.
- Adoption can take various forms, including domestic adoption (within the
same country) or international adoption (from another country).
- Adoptive parents may choose adoption for various reasons, including
infertility, a desire to provide a loving home to a child in need, or as a means
of expanding their family through a different path.
- Adoption offers the opportunity to give a child a stable, loving family
environment and is often pursued by individuals or couples who are unable
to conceive or carry a pregnancy, as well as those who wish to provide a
home for a child in need.
3. **Child-Free Living**:
- Child-free living refers to the conscious decision not to have children.
- Individuals or couples may choose to remain child-free for various
reasons, including personal preference, career aspirations, financial
considerations, health concerns, or a desire for independence and flexibility.
- Child-free living allows individuals or couples to focus on other aspects of
their lives, such as personal growth, career advancement, hobbies, travel,
and relationships.
- Choosing to remain child-free is a valid and fulfilling lifestyle choice that
can provide freedom, autonomy, and opportunities for self-fulfillment.
Each of these alternatives to childbirth offers different paths to parenthood
or living a child-free life, and the choice depends on individual circumstances,
values, and preferences. It's important for individuals or couples considering
these options to carefully evaluate their goals, resources, and readiness for
parenthood, as well as to seek support and guidance from professionals and
support networks as needed.