NUR 235

Gynecology Nursing Course

 Objectives
At the end of the lecture the student will be able to:
1- State definition, types, and incidence of infertility.
2- Discuss male factors for infertility.
3- Explain female factors for infertility.
Identify different clinical and laboratory techniques that are -4
used to enhance fertility
 Definition
 Infertility:
is defined as the inability to conceive a child after 1 year of regular sexual
.intercourse unprotected by contraception

 Sterility: Pregnancy is absolutely impossible

 Types:
Primary infertility: occurs in a women who has never been pregnant.
Secondary infertility: is the inability to conceive after a previous pregnancy.
 Incidence: 10 – 15% of couples are infertile (1:7 marriages)
 Requirements for pregnancy
1. Male must produce satisfactory number of normal motile spermatozoa.
2. Male must have patent vas deference potency to ejaculate spermatozoa into
vagina.
3. The spermatozoa reach the ovum and capable of penetrating and fertilize
the ovum.
4. Female release an ovum to patent fallopian tube.
5. The fertilized ovum move to implant into the endometrium.
6. The embryo must implant & develop normally and produce HCG to
prevent degeneration of corpus lutium
 Risk Factors for Infertility
in Female and Male

Female risk factors

1.Overweight or underweight
Male risk factors
(can disrupt hormone function)
1.Cigarette or marijuana smoke
1.Hormonal imbalances leading to
irregular ovulation 2.Heavy alcohol consumption
2.Uterine fibroids 3.Exposure of the genitals to high
temperatures (hot tubs or saunas)
3.Tubal blockages
4.Obesity is associated with decreased
4.Cervical stenosis
sperm quality
5.Reduced oocyte quality
5.Frequent long-distance cycling or
6.Chromosomal abnormalities running
7.Congenital anomalies of the uterus 6.STIs
8.Chronic illnesses such as diabetes, 7.Undescended testicles
thyroid disease, asthma
8.Mumps after puberty
9.Endometriosis
10.History of PID
 Male Infertility
Incidence: 20 – 40%
Causes:
1. Failure to deposition of spermatozoa in the vagina due to;
hypospadious, epispadious, impotence, or premature ejaculation.

2. Failure in seminal fluid; poor in fructose, prostaglandins, or thick

fluid.

3. Failure in vas deferences or ejaculatory ducts due to; bilateral

obstruction (infection, congenital, trauma,…).

4. Failure in spermatogenesis: aspermia, azoospermia,

astheniospermia, necrozoospermia, or excessive abnormal
spermatozoa.
Diagnosis:
1. History
2. Examination: undescended tests, varicocele, penile deformities, or
atrophied tests.
3. Investigation: semen analysis

Treatment:
1. Medical: diet, no smoking or drinks.
2. Surgical treatment: for obstruction, varicocele, penile deformities.
3. Artificial insemination at time of ovulation
 The normal value of the seminal fluid
Normal semen picture according to WHO standards:

Spermatozoa concentration:
• Volume: more than 2.0 ml
• More than 20 millions per ml
• Morphology 60% normal
• Motility 70% progressive motility at ejaculation,
60% are motile after 2 hours
• No agglutination
• Normal appearance and consistency
• pH between 7.2 and 7.8
 FEMALE INFERTILITY
Tubal factor

Incidence 20-30%

Physiology
1. The fimbria should move at time of ovulation and pick up the ovum.
2. The tubal fluid should be non hostile to sperm or ovum
3. The tubes should be patent.
4. The tubal cilia & peristalsis should be normal to help transportation
of the ovum & zygote
 Etiology of tubal infertility

1. Inflammatory: such as pelvic inflammatory disease (PID) that

caused by gonorrhea or Chlamydia, salpingitis causing destruction
of the cilia, and fibrosis of the fimbria resulting in loss of the pick up
mechanism.
2. Traumatic: salpingectomy
3. Congenital: hypoplasia
4. Neoplastic: Completely blocked fallopian tubes (fibroid), scarring or
other tubal damage.
5. Endometriosis is the important cause for peri-tubal adhesions.
Diagnosis of tubal factors
1. History of infection: puerperal sepsis,
or septic abortion

2. Testing for tubal potency:

***Hysterosalpingogram (HSG): This is an x-ray examination in which

contrast material (dye) is injected through the cervix to the uterine
cavity. If the fallopian tubes are open the dye flows into the tubes
and then spills out to the abdominal cavity.
3. Laparoscope is usually performed early in the menstrual cycle. During
the procedure, an endoscope is inserted through a small incision in the
anterior abdominal wall. Visualization may indicates tubal adhesions or
tubal occlusion.

Treatment: According to the cause.

 Cervical factors

Incidence: 5-10%

Etiology of cervical infertility

1. Congenital: stenosis, elongation, or hypoplasia.

2. Traumatic: cauterization or amputation.
3. Inflammatory: cervical erosion, or cervacitis.
4. Neoplastic: cervical polyp, or fibroid, or cancer.
5. Disturbed physiology: spermagglutination very thick mucus or
mucus contains pus
 Investigation of cervical factors

1. Sperm-pentration test: at time of ovulation, a drop of cervical

mucus is obtained by a pipette, and transferred to a slide.
Husband’s sperm are laid by its side so as to be just in contact with
it. The slide is examined microscopically at intervals. The results is
non-hostile (sperm will enter and remain motile for hours). Is hostile
(sperm fail to penetrate or lose their motility in few minutes.

1. Post-coital test: one drop of cervical mucus between 4-6 hrs after
coitus, the sample is examined for the percentage of motile sperm,
dead sperm, and the presence of bacteria.
 Ovarian factors

Incidence: 18-20%
Etiology:
An-ovulation
Diagnosis:
1. History: asked in details about menstrual history (amenorrhea,
dysmenorrhea, oligomenorrhea, or irregular menstruation, and
duration of menstruation).
2. Pelvic examination: polycystic ovaries.
3. Tests for ovulation
 Tests done to predicate ovulation
1-Basal body temperature (BBT):
body temperature is drops before ovulation, then raised just after
ovulation & remain elevated for at least 3 days.

2. Cervical mucous : it is become thinner , clear, copious and

watery at the time of ovulation. it also show
Frenning pattern when dried on a slide
3. Ovulation prediction kit :
Most accurate methods. The test detects an increased level of
luteinizing hormone (LH) present in an early morning urine sample 1
to 2 days before ovulation.

4. Ultrasound scanning (USS):

to detect a ripening graafian follicle and thickening of the endometrial

5.Hormonal assays:
Blood tests that measure the levels of various hormones, such as
luteinizing hormone (LH), follicle-stimulating hormone (FSH),
prolactin (PRL), estradiol, and progesterone, aid greatly in
determining the cause of infertility
 Treatment
Clomiphene citrate: tablets to induce ovulation.
The clomiphene citrate challenge test is used to assess:
 woman’s ovarian reserve (ability of her eggs to become
fertilized). FSH levels are drawn on cycle day 3 and on
cycle day 10 after the woman has taken 100 mg clomiphene
citrate on cycle days 5 through 9.
 If the FSH level is greater than 15, the result is considered abnormal and the
likelihood of conception with her own eggs is very low
 Uterine factors

Incidence: 3%

Causes:
1. Congenital: septet or subsepetate uterous.
2. Traumatic: heavy curettage & intra-uterine synechia
3. Inflammatory: endometriosis
4. Neoplastic: fibroids
5. Disturbed physiology: retroversion (RVF)
 Principles of Management of the Infertile
Couple
• Privacy is crucial in communicating with the infertile couple.

• Treatment should not be started until all basic investigations

are performed. These include:

a. Semen analysis
b. Tubal patency test
c. Ovulation detection test
d. Laparoscopy
 Artificial Reproductive Technology
Clinical and laboratory techniques that are used
to enhance fertility

1- Artificial insemination

Indications:
1. Oligospermia
2. Cervical factor infertility: poor mucus, hostile secretions or
immunological.
3. Mechanical problem
4. Unexplained infertility
Technique
1- Stimulated cycles
2. semen sample will be processed by the lab in order to separate the
sperm from the seminal fluid. A catheter is used to inject of 0.3 -
0.5c.c the processed sperm directly into the uterus. The IUI
procedure is short and involves minimal discomfort
2-In vitro fertilization & Embryo transfer ( IVF & ET ):

Indications
1. Tubal factor
2. Oligospermia
3. Cervical factor infertility
4. Endometriosis (failed medical & surgical treatment).
Stages of IVF & ET

**Pretreatment screening and proper counseling of the

couple about results before doing it.

1. Induction of ovulation & ovum monitoring by USS.

2. Recovery of oocytes “ oocyte Retrieval ” by
laparoscopy or sonographic guidance when 4
Follicles reach 20mm in size then incubation at 37c
for 4-6 hours

3. IVF processed semen is added to oocytes till

fertilization occurs  left for 36 - 48 hours (2-4 cell
stage)
4. Embryo transfer: 3-4 embryos at 2-4 cell stage (through embryo
transfer catheter) near the funds.
5-Monitoring

Ovum retrieval under U/S guidance

3- Gamete Intra fallopian transfer (GIFT)

** Ova are picked up as before ,aspirated into a catheter with fresh sperm.
Then placed in the distal end of the fallopian tube. Fertilization should then
occur in the tube
 4. Zygote intra fallopian transfer (ZIFT)

**Ova are fertilized outside the body and early stage embryo is the
introduced into fallopian tube

Nursing role

1. Encourage feminine and menstrual hygiene to avoid infection that

may lead to infertility
2. Advice women to seek prompt medical care whenever is infection
3. Explain the problem of infertility with emphasis on effects of stress
and psychological factors
4. Teach newly married women about physiological of conception
5. Encourage infertile couple to seek proper medical care
6. assist in each of the diagnostic test accordingly
7. explain the exact causes of infertility after diagnosis
8. encourage women to stick to treatment and never lose a hope
9. advice regular check up with treatment
10. prepare the women to accept treatment failure and to go on and
never stop
11. listen to women concerns
Thank You