SUBFERTILITY

(INFERTILITY)
Coitus of 4x/week: 65-75% of
couples will conceive within 6
months and 90% within 12 months
Coitus daily: more difficult to
conceive (too frequent can lower
sperm count
The chance of subfertility increases
with age: woman who delay
pregnancy to late 30s is apt to have
more difficulty conceiving
TYPES

a.Primary – no previous conception

b.Secondary – with previous viable
pregnancy but unable
to conceive at present
FACTORS ASSOCIATED with INFERTILITY

a.Reproductive tract
b.Hypothalamic-pituitary-gonadal axis
c. Timing and frequency of intercourse
FACTORS AFFECTING FEMALE FERTILITY
1. Anovulation (most common cause)
Causes:
a. Turner’s syndrome (hypogonadism) – no ovaries to
produce ova
b. hypothyroidism (interferes hypothalamus-pituitary-
ovarian interaction)
c. ovarian tumors
d. chronic/excessive exposure to x-rays or radioactive
substances
e. poor diet
f. stress: reduces hypothalamic secretion of GnRH, which
then lowers the production of LH and FSH
g. decreased body weight/body fat: reduces FSH and LH
h. polycystic ovary syndrome – most common cause
- ovaries produce excess testosterone,
lowering FSH and LH
- associated with metabolic syndrome:
1. waist circumference of 35 and above in women
2. FBS: >100mg/dl
3. triglycerides: >150mg/dl
4. BP: >135/85mmHg
5. HDL: <50mg/dl
Important for adequate ova production:
a. nutrition
b. body weight
c. exercise

* all influence blood glucose/insulin balance

* too high glucose or insulin can disrupt the
production of FSH and LH leading to subfertility
from ovulation failure
 * to increase fertility:
a. maintain ideal body weight
b. diet
CHO: brown rice, pasta, dark bread, beans,
fiber-rich vegetables
unsaturated fat: plant sources
such as corn or olive oil
CHON: plant sources such as soybeans,
tofu, beans, nuts
c. exercising 30 minutes a day by walking or
mild aerobics (helps regulate blood glucose
level)
2. Tubal Transport Problems
Causes:
a. reduced motility
b. absence of fimbriae
c. absence of tubes
d. adhesions
e. inflammation (PID) – causes
scarring of the fallopian tubes
that can lead to strictures
3. Uterine Problems
Causes:
a. fibroma (tumor)
b. Poor secretion of estrogen or
progesterone: result in inadequate
endometrium formation, interfering with
implantation
c. endometriosis – implantation of
endometrium or nodules that spreads
from the interior to outside the uterus
d. congenitally deformed uterine cavity
(bicornuate uterus)
bBicornuate
Uterus
4. Cervical Problems
Causes:
a. thick cervical mucus
b. obstruction
c. frequent dilatation and curettage –
causes scar tissue and tightening of the
cervical os
5. Vaginal problems
Causes:
a. infection – causes acidotic vaginal pH,
limiting the motility of
spermatozoa
FACTORS AFFECTING MALE FERTILITY
1. Disturbance in spermatogenesis/inadequate sperm count
Causes: a. increase body temperature: chronic infection
b. increase scrotal heat: salesmen, motorcylcists. Frequent
use of hot tubs or saunas
c. cryptorchidism
d. varicocele – increases heat within the testes
e. trauma
f. surgery – results in impaired testicular circulation
g. endocrine imbalances
h. use of excessive alcohol, smoking
i. drug abuse
j. exposure to x-rays or radioactive substances
- men should be provided with adequate protection of the
testes/protective lead testes shield
2. Obstruction or Impaired Sperm Motility
Causes: a. mumps orchitis
b. epididymitis
c. tubal infections: gonorrhea, urethral
d. congenital stricture of spermatic duct
e. BPH
f. prostatitis
g. autoimmune from vasectomy or infections
h. hypospadias/epispadias
i. extreme obesity: interfere with effective
penetration and deposition
j. smoking
k. drug abuse
3. Impotence/erectile dysfunction
Causes: a. psychological problems
b. CVA
c. DM
d. Parkinson’s dse.
e. antihypertensive drugs
f. alcohol
Interventions:
a. psychological or sexual counseling
b. Sildenafil (Viagra)
FERTILITY ASSESSMENT
1. Health history
2. Physical assessment
a. Presence of secondary sexual characteristics
and genital anomalies
3. Fertility Testing
a. Semen Analysis
b. Ovulation Monitoring
c. Test for Tubal Patency
Semen Analysis
- includes motility and ability to penetrate an
ovum
- is usually collected by masturbation
- may need to be repeated after 2-3 months,
because spermatogenesis is an ongoing
process, and 30-90 days is needed for new
sperm to reach maturity
 Preparation: abstinence for 2-4 days

Procedure:
a. collect specimen into a clean, dry container
b. send into the laboratory in a sealed
container within 1 hour after ejaculation
c. do not expose to excessive heat or
cold
Normal:
a. average ejaculation should produce
2-5 ml of semen
(minimum of 1.4 to 1.7 mL)
b. 20-200 M/ml
(minimum of 33 to 46 million/mL)
c. pH: 7.2-7.8
d. at least 50% are motile
e. at least 33% are normal in shape and
form
Ovulation monitoring
a. measure progesterone level during
luteal phase (fastest way)
* level increases during ovulation
b. Record BBT daily for at least 4 months
(early morning before rising)
• BBT increases immediately after
ovulation and should last
approximately 10 days
• If not, it may suggests progesterone
production is not sustained
Tubal Patency
1. Sonohysterography (transvaginal ultrasound)
- can be done anytime during menstrual period
2. Hysterosalpingography (x-ray study)
- introduction of iodine-based radiopaque into
the cervix followed by an X-ray
- done after menstrual flow when pregnancy
could not be present
Normal: the material outlines the uterus and both
tubes
Therapeutic effect: the pressure of the solution may
break up adhesions as it passes through
the fallopian tubes
4. Advanced Surgical Procedures
a. uterine endometrium biopsy
- less common
- done 2-3 days before an expected
menstrual flow
- mild-moderate discomforts during
maneuvering of the instruments
- sharp pain as specimen is taken
- small amount of vaginal spotting
after the procedure
b. hysteroscopy
c. laparoscopy

- introduction of a thin, hollow, lighted tube

through a small incision in the abdomen,
just under the umbilicus
- allows the examiner to view the proximity
of the ovaries to the
fallopian tubes
- under general anesthesia
- trendelenburg position
NURSING DIAGNOSES

1. Disturbed body image or Risk

for low self-esteem r/t impaired
fertility
2. Social isolation r/t impaired
fertility
MANAGEMENT
1. Non-medical
Change in lifestyle:
a. For men:
- Avoid prolonged/frequent hot tubs/saunas
- wear loose clothing
- avoid long periods of sitting
b. For women with immunologic reaction to
sperm (with anti-sperm antibody):
- use of condoms for 6-12 months: reduces
female antibody production
- after serum reaction subsides, condoms are
used at all times except during ovulation
c. well-balanced diet
d. decrease alcohol intake
e. no smoking/drug abuse
f. stress management/relaxation
2. Medical (hormone therapy)
Disturbance in ovulation:
a. GnRH
b. Clomiphene citrate (Clomid, Serophene) –
stimulates ovulation
d. Combinations of FSH and LH with human
chorionic gonadotropin – to produce
ovulation
• Clomiphene citrate or Gonadotropins:
>25% for possible multiple pregnancy
Scant cervical mucus:
a. Low-dose estrogen therapy:
Conjugated estrogen (Premarin)
– to increase mucus production

Low estrogen level:

a. Conjugated estrogen and
medroxyprogesterone

Luteal phase defect:

a. Hydroxyprogesterone
(vaginal suppositories/IM)
For adhesions:
a. hysterosalpingography
b. steroids – from inflammation
Hypogonadism in men:
a. FSH,Clomiphene citrate
- stimulate spermatogenesis
Others:
a. Vitamin E
b. Calcium
c. Magnesium
3. Surgical
a.Removal of tumors
b.Repair of the damaged tube
c. Hysterosalpingography – for
blockage or adhesions
d.Reconstructive surgery
e.Repair of varicocele
4. No surgical treatment for small uterus

- after 2-3 miscarriages, a woman

may finally give birth to a viable
infant
- actual growth of the uterus occurs
with each pregnancy
6. Reproductive alternatives
a. Therapeutic/Alternative Insemmination
- sperm is instilled directly into the cervix or
uterus from either husband or donor
Indications: low sperm count or vaginal or
cervical factor that interferes with sperm
motility
Sperm Bank (frozen sperm/cryopreserved):
Disadvantage: has lower motility
Advantage:
a. no incidence of congenital anomalies
b. can be used even after years of storage
Procedure:
1. woman receives 1 month injection of
Clomid or FSH
2. to predict ovulation on the day of
insemination:
a. serum analysis of progesterone
b. a woman must record her BBT, assess
her cervical mucus, or use an ovulation
predictor kit to predict her day of
ovulation
c. on the day after ovulation, the sperms
are instilled
b. In Vitro Fertilization-Embryo Transfer (IVF-ET)
- removal of oocytes from ovary by laparoscopy
and fertilized in the laboratory, 40 hours after
fertilization, ova are transferred into a woman’s
uterus transvaginally.
- 25% ends in spontaneous miscarriage
- pregnancy rate: 46-59% (aged 30-35)
Indications:
a. blocked or damaged fallopian tubes
b. cervical factor
c. immunologic infertility (antisperm antibodies)
d. very low sperm count/severe male infertility
Procedure:
a. ovulation-stimulating agent:
GnRH or Clomiphene citrate (Clomid) 1 month prior
b. On the 10th day of menstrual cycle, the ovaries are examined
daily by ultrasound to assess the number and size of developing
ovarian follicles
c. when follicle appears to be mature, a woman is given an injection
of HCG, which causes ovulation in 38-42 hours.
d. oocytes are aspirated as many as 3-12, incubated for 8 hours to
ensure viability
e. sperm cells and eggs are mixed for fertilization
f. after 40 hours, 1-2 zygotes are transferred back into the uterus
g. routine serum pregnancy test as early as 11 days after transfer to
detect implantation
c. Gamete Intrafallopian Transfer (GIFT)
Pregnancy rate: 38-50%
Procedure:
a. oocytes are retrieved from the ovary exactly
as in IVF
b. placed in a catheter with motile sperm and
immediately transferred into the fimbriated
end of the fallopian tube
c. fertilization occurs in the fallopian tube

Indications: same as IVF

Contraindication: blocked/damaged fallopian tubes
d. Zygote Intrafallopian Transfer (ZIFT)
Pregnancy rate: 59%
Procedure:
a. removal of oocytes by transvaginal
ultrasound-guided aspiration
b. fertilized in the laboratory
c. within 24 hours, zygotes are
transferred by laparoscopic technique
into the end of the fallopian tube

Indications: same as GIFT

e. Surrogate Embryo Transfer (Donor Oocyte)
Procedure:
a. menstrual cycles of the donor and recipient are
synchronized by administration of gonadotropic hormones
b. during ovulation, the donor’s ovum is removed
by transvaginal ultrasound-guided procedure
c. fertilization occurs in the laboratory by the
recipient woman’s partner’s sperm (or donor sperm)
d. fertilized egg is placed in the recipient woman’s
uterus by embryonic transfer

Indication: woman who does not ovulate