Chapter 7

Nursing Care of the Family Having

Difficulty
Conceiving a Child
Overview #1

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
Subfertility: term used rather than “infertility”
because it denotes that couple has a potential to
conceive
o Affects 8% to 12% of couples desiring children

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Overview #2

Primary subfertility: no previous conceptions

Secondary subfertility: previous pregnancies
occurred; however, couple is not able to presently
conceive
Sterility: inability to conceive due to known cause
such as absence of a uterus

Copyright © 2018 Wolters Kluwer · All Rights Reserved

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

Copyright © 2018 Wolters Kluwer · All Rights Reserved

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

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Sub fertility. . ..

 In about 40% of couples with a subfertility problem, the

cause of subfertility is multifactorial
 In about 30% of couples, it is the man who is subfertile;
in 70%, it is the woman.
 Of women seen for a fertility evaluation, 20% to 25%
experience ovulatory failure; another 20% experience
tubal, vaginal, cervical, or uterine problems.
 In about 10% of couples are categorized as having
unexplained subfertility

Copyright © 2018 Wolters Kluwer · All Rights Reserved

2020 National Health Goal
Related to Subfertility

Reduce the proportion of woman aged 18 to 44

years who have impaired fecundity (fertility) from
12% to a target of 10.8%.

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Fertility Assessment: Health History #1

Health history (both partners)

o General health
o Nutrition
o Alcohol, drug, or tobacco use
o Congenital problems of reproductive tract, past STDs or
genital tract surgery
o Current illnesses
o Contraceptive history and pregnancies in previous
relationships
o Occupational/lifestyle hazards

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Fertility Assessment: Health History #2

 Health history (male partner)

o Radiation to testes (cancer treatment, occupational
exposure, diagnostic X-rays)
o Sexual practices (frequency of coitus, masturbation, coital
positions, failure to ejaculate)

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Fertility Assessment: Health History #3

Health history (female partner)

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

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Fertility Assessment: Physical Assessment

Male partner
o Secondary sex characteristics
o Genital abnormalities

Female partner
o Secondary sex characteristics
o Genital abnormalities
o Breast and thyroid examination

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Fertility Testing:
Answering the Three Basic Questions

Is there sperm of good quality, number, and motility

available?
o Semen analysis

Are ova available?

o Ovulation monitoring

Can sperm and ovum meet in a receptive

environment?
o Assessment of fallopian tube patency

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Fertility Testing: Semen Analysis

Number of sperm
Appearance of sperm
Motility of sperm
Sperm penetration

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Fertility Testing: Ovulation Monitoring

Ovulation monitoring
o Measurement of woman’s serum progesterone level during
luteal phase of menstrual cycle
o Recording of basal body temperature
o Measurement of urine LH upsurge (urine test strip)

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Basal Body Temperature

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Fertility Testing: Tubal Transport
(Tubal Patency)
Sonohysterosalpingogram
Hysterosalpingogram
Transvaginal hydrolaparoscopy

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Insertion of Contrast Medium

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Fertility Testing: Uterine Concerns

Hysteroscopy
Uterine endometrial biopsy
Laparoscopy

Copyright © 2018 Wolters Kluwer · All Rights Reserved

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
 Ligation of a varicocele (if present) and changes in
lifestyle, such as avoiding recreational marijuana use,
wearing looser clothing, avoiding long periods of sitting,
and avoiding prolonged hot baths

Copyright © 2018 Wolters Kluwer · All Rights Reserved

OBSTRUCTION OR IMPAIRED SPERM
MOTILITY

 adequate sperm are manufactured, but there is

obstruction
 Diseases such as mumps orchitis (testicular inflammation
and scarring due to the mumps virus), epididymitis
(inflammation of the epididymis)
 infections such as gonorrhea or ascending urethral
infection can result in this type of obstruction Congenital
stricture of a spermatic duct may occasionally be seen.
 Benign hypertrophy of the prostate gland occurs in most
men beginning at about 50 years of age.
 Pressure from the enlarged gland on the vas deferens
can then interfere with sperm transport.
 Infection of the prostate
 infection of the seminal
Copyright © 2018 Wolters Kluwer · All Rights Reserved
Examples of Nursing Diagnoses Related to
Subfertility

Knowledge deficit related to fertility testing

Anticipatory grieving related to failure to conceive or
sustain a pregnancy

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Examples of Nursing Diagnoses and
Outcomes Related to Subfertility

Nursing Diagnosis Outcomes

Knowledge deficit related to fertility Couple will understand the
testing processes related to fertility
testing.
Anticipatory grieving related to Couple will successfully resolve
failure to conceive or sustain a their grieving process.
pregnancy

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Quality & Safety Education for Nurses
(QSEN)

Patient-Centered Care
Teamwork & Collaboration
Evidence-Based Practice
Quality Improvement
Safety
Informatics

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Interventions Related to Subfertility

Nursing Diagnosis Possible Nursing Interventions

Knowledge deficit related to fertility • Review with the couple the basic
testing aims of fertility testing and
related diagnostic procedures.
Anticipatory grieving related to • Explore the importance of and
failure to conceive or sustain a meaning placed on having
pregnancy children with the couple.
• Explore with the couple their
openness to alternatives to
childbirth.

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Evaluating Outcomes Related to
Subfertility

Nursing Diagnosis Expected Outcomes

Knowledge deficit related to fertility Couple can correctly describe some
testing of the basic fertility tests and why
they are performed.
Anticipatory grieving related to
failure to conceive or sustain a ?
pregnancy

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Question #1

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.”

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Answer #1

A. “The kit has detected an increased presence of

luteinizing hormone (LH) in the urine.”
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.

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Question #2

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?
A. An elevated estrogen level
B. An elevated FSH level
C. A failure to ovulate
D. An elevated progesterone level

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Answer #2

C. A failure to ovulate
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 (also see Fig. 7.1 in the text).

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Question #3

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?
A. Transrectal and scrotal ultrasound testing is routinely
performed in the male.
B. Semen analysis is usually not performed until all tests in the
female partner are negative.
C. Testing for tubal patency is performed during the same time
period as ovulation monitoring is being done.
D. Fertility testing usually begins with ovulation monitoring in the
woman.

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Answer #3

D. 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.

Copyright © 2018 Wolters Kluwer · All Rights Reserved