Nursing Care of The Couple Experiencing Infertility

1. Nursing Care of The Couple Experiencing Infertility

2. Infertility inability to achieve conception after one year of unprotected intercourse.

3. Factors Contributing to Infertility

4. Factors in the Male 1. Abnormalities of the Sperm 2. Abnormal erections 3. Abnormal ejaculation 4. Abnormalities of seminal fluid 5. Obstructed genital tract - ducts need to be open to carry sperm to the penis for ejaculation. 6. Lack of Normal hormones -- androgens

5. Factors in the Female A woman’s fertility depends upon: • FAVORABLE CERVICAL MUCUS – mucus that is not too acidic and kill off the sperm. Must also be thin, watery, stretchable to allow the sperm to get through. • CLEAR PASSAGE BETWEEN CERVIX AND TUBES – no abnormal strictures in the tubes • PATENT TUBES WITH NORMAL MOTILITY – fallopian tubes have peristalsis and movable cilia that assist the fertilized ovum to move from the distal end to the proximal end ( uterus).

6. 4. Ovulation and Release of Normal Ova – the woman must release an egg each month. 5. Endometrium prepares for implantation -- endometrium must get thick and have nutrients ready to support the fertilized ovum. Must have normal shaped uterus.

7. Answer this! During assessment, the nurse discovers that the patient’s medical history includes a ruptured appendix and resulting peritonitis several years ago. Why might this data be pertinent to the patient’s infertility problem? a. the infection may have caused sterility b. resulting scarring and adhesions may have caused tubal blocking c. the appendix plays an important role in tubal functioning

8. Answer • Correct answer is B. • This patient does not meet the criteria of having a clear passageway with normal peristalsis and cilia.

9. Assessment of Male Fertility

10. Semen Analysis • Procedure: • Specimen is collected after 3 - 4 days of abstinence. • The man ejaculates into a clean, dry specimen container or condom and takes it to the lab for study. • The sperm are examined under microscope within 1 hour of collection Usually do about 3 analysis for more reliable data. *Make sure not to get the specimen too hot or cold!

11. Semen Analysis Assess for: • Number, appearance, motility • Amount--average ejaculation is about 5 cc. with a minimum of 20 million sperm/ ml. of fluid (Normal count is 50 - 200 million/ ml. of fluid) • Semen pH 7.2-7.8 • Liquification – usually occurs in 30 min. • Fructose

12. Ask Yourself In assessing the adequacy of sperm for conception which of the following is the single most useful criterion? a. sperm count b. sperm appearance c. sperm motility d. semen volume

13. Answer • C is correct answer. Must have motile sperm to make the journey to the distal portion of the tube. • Can bank from several ejaculations to increase the sperm count, semen volume is not that important.

14. Hormonal Testing • Testosterone • LH and FSH Other Testing • Urinalysis • Ultrasound • Testicular biopsy • Sperm penetration assay

15. Assessment of Woman’s Fertility Usually start from the more non-invasive tests to the more invasive

16. Evaluation of Ovulatory Functions • Basal Body Temperature Teach the woman to assess for the drop andthen risein her temperature as ovulation occurs Look for the check-mark on the graph. Teach about factors that may alter temperature: infection, fatigue, less than 3 hours of sleep, awakening late, sleeping in a heated waterbed or under a heating blanket, jet lag. Monitor BBT for 3 - 4 months to be effective.

17. Basal Body Temperature Record

18. Hormonal Function Testing Gonadotropins (FSH and LH) - assess LH surge that should occur immediately before ovulation. Used for ovulation prediction. Progesterone assays – measured toward the end of the cycle to assess if the levels remain high. Tells more about the ovulation and corpus luteum functioning. Endometrial Biopsy – usually done toward the end of the cycle to assess secretory function and if the endometrium has the nutrients and is thick. Transvaginal Ultrasound – best used for follicular monitoring.

19. ENDOMETRIAL BIOPSY • Procedure: This test is performed after ovulation during the luteal phase of the menstrual cycle about 2 - 4 days before the expected menses. A sample of the endometrium is removed and sent to the lab for study. • Purpose: Assess the corpus luteum and the receptivity of the endometrium for implantation. (Did it make a good home?) Responding from estrogen and progesterone stimulation.

20. Cervical Mucus Testing • Ferning Test The maze like strands align in a parallel manner to allow for easy sperm passage during ovulation • Cervical Mucus Testing Teach the appearance of the cervical mucus at various stages of the menstrual cycle. At time of ovulation becomes thin, watery, clear.

21. Evaluation of Cervical Factors • Spinnbarkheit • Teach the woman to assess for stretchability of the mucus. Put mucus between two fingers and pull apart and assess stretchability. At time of ovulation, the mucus should stretch 8-10 mm

22. POST COITAL EXAMINATION/ Huhner • Purpose: Test the ability of the sperm to survive the cervical barrier and its secretions • Procedure: 1. Assess time of ovulation and have intercourse 2. Go to health facility within 2 - 8 hours after sex 3. Semen and cervical mucus are retrieved by aspiration with a catheter and then tested. • Test for: quality of cervical mucus, sperm penetration through the mucus, number of active sperm, and signs of infection.

23. Hysterosalpingography Primarily used to examine women who have difficulty becoming pregnant by allowing the radiologist to evaluate the: • shape and structure of the uterus • the openness of the fallopian tubes • peritoneal cavity for any scarring, adhesions

24. Hysterosalpingography Instill a radiopaque dye into the uterine cavity under pressure. The substance fills the uterus, tubes, and spills into the peritoneal cavity. Viewed with x-ray

25. Hysterosalpingography Reveals tubal patency and any distortions of the uterus / endometrial cavity Can be therapeutic by flushing debris, breaking adhesions, and just clearing the tubes. Can cause uterine cramping and referred shoulder pain.

26. Laparoscopy • Under general anesthesia, entry made through an incision in the umbilical area. • Peritoneal cavity is distended with carbon dioxide gas • Pelvic organs are visualized with a fiber optic instrument • Dye can be injected into the uterus and up the tubes to check patency. • The pelvis can be evaluated for adhesions, cysts, tumors, and endometriosis

27. Hysterscopy • Visual inspection of the uterus through the insertion of a scope through the cervix. • Usually follows a hystersalpingography

28. Therapies to Facilitate Pregnancy

29. Treatment for Male and Female • Treat the underlying cause: • If an infection is found, treat with antibiotics • If either have abnormal genital structures, may do surgical correction, or reconstruction. • Teach measures that promote fertility- non-medical therapies.

30. Try this! The Nurses’ teaching for potentially increasing fertility would include which of the following initially? a. Reduce frequency of intercourse to less than once a week b. Clarify the validity of the degree of sexual satisfaction c. Instruct them to eliminate any additional lubrication

31. Answer • C (Lubricants can act as a spermicide.)

32. Medications

33. Clomiphene Citrate (Clomid) • Action: stimulates follicular growth by increasing secretion of FSH and LH • Success- 40% become pregnant • Patient Teaching Take the drug for 5 days starting day 5-9 of menstrual cycle. Usually start with 50 mg. and increase to 250 mg.

34. Side Effects of Clomid • Anti-estrogenic may cause: • a DECREASE in cervical mucus production • Hot flashes • Abdominal Bloating • Breast Tenderness • Nausea and Vomiting • Ovarian enlargement • Visual Disturbances

35. Human menopausal gonadotropins • Human menopausal gonadotropin Stimulates follicular development. Formed from the combination of FSH and LH obtained from postmenopausal women’s urine Administered IM every day for various times during the first half of the menstrual cycle. Dose is based on serum estradiol and ultrasound finding. The Woman is taught to give her own injections. **Drug may overstimulate ovaries and end up with multiple births

36. Other Pharmacologic Agents • Parlodel - Acts directly on prolactin-secreting cells inhibiting their secretion of prolactin. Since prolactin blocks the production of FSH and LH, now they are free to stimulate ovum development. • Chorionic Gonadotropins – trigger shot to cause release of the ovum. • GnRH agonists – Lupron, synarel – induce ovulation See Table 10-4 on page 208

37. Surgical Procedures

38. Reproductive Alternatives

39. Therapeutic Insemination • May use either the Husband’s Semen (THI) or that of a donor (TDI). • The conception rate is: • 30% with donor’s semen • 15% with husband’s semen. Lower because of the lack of sperm or something wrong with the husband’s sperm • Sperm is “washed” and placed in a cervical cup and deposited at the cervical os or directly in the uterus with a small catheter. • The woman is to remain in supine position with hips elevated for about 20 - 30 minutes

40. Reminder!! Fresh sperm cannotfertilize an ovum, it must be capicitated “washed” first. (Capicitation is the act of separating the sperm from the semen and diluting it). This process also removes many of the antibodies that interfere with sperm motility and ability to penetrate the ovum. Normally following intercourse, the cervical mucus removes the seminal fluid.

41. Advanced Reproductive Techniques

42. In Vitro Fertilization Used in Couples in which: Woman has blocked or damaged fallopian tubes Male sperm count is low Infertility is long-term and unexplained

43. In Vitro Fertilization Procedure • Ovulation is induced using fertility drug( Lupron, Follistim, Gonal F, Clomid) Ovarian function is monitored. Pregnly or Profasi given to assist with release of egg from corpus luteum. 2. Ripened, mature ova are aspirated from the ovaries during laparoscopy

44. In Vitro Fertilization 3. The ova are incubated for at least 8 hours then transferred to culture media 4. Sperm that have been capicitated are added to the ova in a perti dish 5. After fertilization, zygotes are allowed to grow and then transferred to the uterus through a catheter. 6. The woman may be give Progesterone injections to enhance receptivity of the endometrium to implantation.

45. Gamete Intrafallopian TransferGIFT • Ovulation is induced similar to IVF • The ova are retrieved and they are placed directly into the fallopian tube along with the male’s sperm. • This allows for fertilization to take place in the fallopian tubes • Success rates are higher • More acceptable since fertilization does not occur outside the body

46. Tubal Embryo TransferZygote Intrafallopian Transfer Fertilization occurs outside body Placed in the fallopian tubes so can enter the uterus naturally for implantation

47. Microsurgical Assisted Fertilization • Small slit made into zona pellucida cells that surround the ovum to allow sperm to gain access • Intracytoplasmic sperm injection – sperm injected directly into the egg.

48. Reproductive Techniques • Legal considerations must be discussed. • Psychological impact must be discussed. Are both of the couple in favor of this choice of conception? • Semen is screened for HIV and other diseases

49. Advanced Reproductive Techniques can cause much controversy and criticism • Costs several thousand dollars and the chances of success are minimal, (only 10%) • Must deal with chance of Multifetal pregnancies and / or Selective Reduction • Major psychological and economic strain on the couple • Influenced by the couples cultural, psychosocial background.

50. THE END