Lecture Seventeen: The Client Experiencing Infertility

1. Lecture Seventeen: The Client Experiencing Infertility NURS 2208 Fall 2002 T. Dennis RNC

3. Definitions Infertility: lack of conception despite unprotected sexual intercourse for at least 12 months; diminished ability to conceive. Sterility: Inability to conceive or produce offspring. Subfertility: a couple having difficulty conceiving because both partners have reduced ability to reproduce. Spinnbarkheit: the elasticity of the cervical mucous that is present at ovulation. Huhner test: postcoital examination to evaluate sperm and cervical mucous. Artificial insemination: introduction of viable semen into the vagina by artificial means for the purpose of impregnation.

4. Definitions In Vitro Fertilization (IVF): procedure during which oocytes are removed from the ovary, mixed with spermatozoa, fertilized, and incubated in a glass petri dish; then up to four viable embryos are placed in the woman�s uterus. Gamete intrafallopian transfer (GIFT): retrieval of oocytes by laparoscopy; immediately combining oocytes with washed motile sperm in a catheter; and placement of the gametes into the fimbriated end of the fallopian tube. Zygote intrafallopian transfer (ZIFT): retrieval of oocytes under ultrasound guidance followed by in vitro fertilization and laparoscopic replacement of fertilized eggs into fimbriated end of the fallopian tube.

5. Infertility (pg. 178) Infertility affects couples emotionally, psychologically, and economically. Approximately 8% of couples in their reproductive years are infertile. Subfertility occurs when both partners have a reduced ability to reproduce. Primary infertility: women who have never conceived. Secondary fertility: women who have been pregnant in the past but have not conceived during one or more years of unprotected intercourse or cannot sustain a pregnancy. Professional intervention can assist 65% of infertile couples achieve pregnancy.

6. Essential Components of Fertility Female: Cervical mucous must be favorable for transport of sperm Fallopian tubes must be patent Ovaries must produce and release No obstruction between ovaries and uterus Endometrium in adequate physiologic state. Adequate reproductive hormones. Male: Testes must produce sperm of normal quantity, quality, and motility. Genital tract not obstructed. Genital tract secretions normal. Ejaculated sperm are deposited in vagina so that they reach the cervix (viable for 48 � 72 hours).

7. Preliminary Investigation Refer for infertility evaluation if lack of conception despite unprotected sex for at least one year � if client is > 35 years old or if history predisposes her to infertility refer after six months. (? age = ? infertility). Time, financial, and emotional strain on the relationship occurs when the evaluation begins (self-esteem, cultural). Approximately 3 to 4 months are required for a thorough evaluation. Treatment averages months to years. Determine if timing of intercourse and length of coital exposure have been adequate. Comprehensive history and physical exam. Hx of ovarian function, cervical mucus, receptivity to sperm, sperm adequacy, tubal patency, and condition of pelvic organs. (pg. 180) Semen analysis A costly, time consuming, emotional investment is begun with initial evaluation. (pg. 181)

8. Testing (pg. 179) The easiest and least intrusive infertility testing approach is used first. A thorough history is taken on both partners. Basal body temperature (BBT): aids in identifying follicular and luteal phase abnormalities. Special thermometer, temp taken every morning before getting out of bed and graphing the temperature (pg 183). Endometrial biopsy: tissue from the endometrium is used to determine effects of progesterone and endometrial receptivity. Transvaginal ultrasound: method of choice for follicular monitoring of women undergoing ovulation induction cycles and for timing ovulation for insemination. Ferning capacity: method of determining crystallization of cervical mucus to determine if ovulation has occurred (pg. 184). Laparoscopy: Exam of the pelvic structure by inserting a small endoscope through an incision in the abdomen.

9. Client Assessment (pg.180) Female: BBT Hormonal assessments Endometrial biopsy Transvaginal ultrasound Cervical factors Evaluation of uterine structures and tubal patency Male: Semen analysis

10. Basal Body Temperature (BBT) (pg. 180) Only use BBT thermometer (measures 96 -100 F, is calibrated to a tenth of a degree to denote very slight temperature changes). Take every morning before rising (after 6-8 hrs uninterrupted sleep). Record on a temperature graph. Should see a biphasic pattern during the ovulatory cycle (pg.183). Detect ovulation to plan intercourse. Pre-ovulatory temp < 98 F. Release of egg occurs 24 to 36 hrs prior to first temp elevation. Intercourse every other day beginning 3 � 4 days prior to and continuing for 2-3 days after expected ovulation.

11. Hormonal Assessments of Ovulatory Function (pg.182 ) FSH: assess ovarian reserve and function LH: day of maximum LH surge is time of maximum fertility. Progesterone: levels rise with LH surge and peak about 8 days later. Prolactin: increased prolactin levels are frequently the cause of ovulatory dysfunction. Thyroid stimulating hormone (TSH): stimulates prolactin secretion (Hypothyroidism has a dramatic effect on ovulatory function). Androgen levels: androgen excess may lead to oligomenorrhea, anovulation, and amenorrhea.

12. Endometrial Biopsy (pg.182 ) Provides information about the effects of progesterone produced by the corpus luteum after ovulation and endometrial receptivity. Performed not earlier than 10 to 12 days after ovulation (pelvic discomfort, cramping, vaginal spotting during and following the procedure). Onset of menses following biopsy noted for accurate interpretation of biopsy report. Dysfunction is diagnoses if endometrial lining does not show that the expected amount of secretory tissue for that day of the cycle. A repeat biopsy may be need to confirm luteal phase dysfunction.

13. Transvaginal Ultrasound (pg. 183) Method of choice for follicular monitoring of women undergoing ovulation induction cycles, for timing ovulation for insemination, intercourse, for retrieving oocytes for in vitro fertilization, and monitoring of early pregnancies.

14. Cervical Factors (pg. 183) To be receptive to sperm, cervical mucus must be, profuse, alkaline and acelluar. As ovulation approaches, mucus increases and water content rises significantly. Mucus elasticity or Spinnbarkheit increases and viscosity decreases (excellent when mucus is stretched 8 to 10 cms or longer). Ferning capacity (crystallization) occurs due to decreased levels of salt and water. 24 to 48 hours after ovulation, there is a marked decrease in these factors. Causes of an inhospitable cervical mucus: ?estrogen secretion, cervical infection, GYN procedures, medications, secretory immunologic reactions. Treatment: estrogen therapy and intrauterine insemination. Huhner test: postcoital test performed 1-2 days after expected date of ovulation. Evaluates cervical mucus, sperm motility.

15. Uterine Structures and Tubal Patency (pg.186 ) Hysterosalpingography (HSG): Instill radiopague substances into the uterine cavity Fill uterus, tubes, and spills into peritoneal cavity viewed on x-ray. Tube patency and uterine abnormalities. Water based dye: brushes away debris, breaks peritoneal adhesions, stimulates cilia, and improves cervical mucus. Performed during follicular phase (days 1 to 14) so as not to interrupt pregnancy. Moderate discomfort, referred shoulder pain (increased with sitting position and cramping (may cause recurrence of PID). Correct with knee-cheat position, OTC prostaglandin inhibitors, disappears in 12 hours (prophylactic antibiotics).

16. Uterine Structures and Tubal Patency (pg.186 ) Hysteroscopy: Done with laparoscopy to look into the uterus to determine if any structural abnormalities are present. Laparoscopy: Direct visualization of the pelvic organs done 6 to 8 months after the HSG (HSG may be therapeutic). Done as outpatient procedure with general anesthesia. Three puncture sites, carbon dioxide to distend the abdomen (biopsy or remove adhesions). Post surgery: Discomfort related to gas in abdomen, pain meds, supine position, and resume activities in 24 hrs.

17. Male Assessment (pg.187) Semen Analysis: Specimen obtained 2-3 days after abstinence by masturbation or special condom (without lubricant). Taken to lab within two hours of ejaculation (avoid heat or cold). May do repeat semen analysis (minimum of 2, if testicular insult wait 2.5 months). Determines: motility, morphology, number Anatomic or endocrine problems: ?scrotal heat (hot tubs, occupation sitting), heavy use of marijuana, alcohol, cocaine within 2 years of testing can ?sperm count & testosterone levels, cigarette smoking decreases motility, medications may cause neurological ejaculatory dysfunction, lead and pesticide exposure ? sperm count, and autoimmunity to sperm development.

18. Pharmacologic Management (pg. 188) Clomid (clomiphene citrate) : if normal ovaries, normal prolactin levels, and an intact pituitary gland. Increases secretion of FSH, LH, and stimulates follicular growth. Induces ovulation in 80%, pregnancy in 40%, and multiple gestation in 5%. Usual dosage is 50 to 250 mg/ day for 5 days, starting from 3 to 5 days after last menses. Estrogen may be needed if there is a decreased amount of cervical mucous. Ovulation occurs 5 to 10 days after last dose. May be assessed by LH kit, BBT, US, progesterone assays, and endo-biopsy. Assess for hyperstimulation: ovarian enlargement, bloating, hotflashes, breast discomfort, abdominal distention, N&V, blurred vision, and mood swings. Sex every other day for 1 week beginning five days after the last day of meds. If no period, do a pregnancy test before Clomid can be re-prescribed.

19. Artificial Insemination (pg.191 ) Artificial insemination: depositing partner�s or donor�s sperm at the cervical os or in the uterus by mechanical means. Indications: Low sperm count, decreased motility, low percentage, abnormal morphology, unexplained infertility, hypospadius. Donor insemination is considered in cases of an absence of sperm, inherited male sex linked disorders. Donor sperm: screening process, sperm frozen for 6 months and quarantined, then donor retested for any disease process, genetic disorders. Takes 6 to 8 cycles of well times insemination to initiate pregnancy.

20. In Vitro Fertilization (pg.192) Infertility has resulted from tubal factors, cervical mucus abnormalities, male infertility, unexplained infertility, immunologic infertility, and cervical factors. Fertility drugs used to induce ovulation and egg retrieved transvaginally. Woman�s eggs are collected and fertilized in the lab then placed in the uterus after normal embryonic development has begun. 3-4 embryos are placed as opposed to one. Client is restricted to minimal activity for 12 to 24 hours and progesterone supplements are begun. An average of three cycles are required for success and the rate of multiples is 30% to 50%.

21. Nursing Care (pg. 195) Financial, physical, and emotional resources are affected. Emotional needs, quality of the relationship. Spontaneity in relationship is stressed. Clients may experience guilt, shame, loss, and depression. Promote appropriate resources and accurate information Adoption may be a possibility for this couple.

22. Questions

23. Our emergency department was trying different types of exam lights in the OB/GYN room. One afternoon, a patient was on the table prepared for a pelvic exam. As the doctor began the procedure, the nurse positioned one of the new lights, and said, �What do you think, Doctor?� The doctor replied, �Well, I�ve seen better.� The doctor had some fast explaining to do when the patient raised her head, and said, �Well, my husband�s never complained.�