Infertility and Contraception Lecture 14

1. Infertility and Contraception Lecture 14

2. Infertility: inability to conceive > 1 year of regular sexual intercourse without contraception or inability to carry pregnancy to live birth. • Incidence – 15% of couples of child-bearing age in U.S. 2.5 million American couples • Primary infertility- no previous conceptions. • Secondary infertility- previous birth but unable to conceive now.

3. Fertility Testing Procedures • Semen analysis (inexpensive) • FSH, LH, estrogen, progesterone levels (blood test) Ovulation Determination by: Basal Body Temperature (temp. slightly just before, then ~ 98.6 immediately > ovulation) ^ by ~ 1 degree (12-24 hours) 1st thing in morning before anything. Daily temps. plotted on graph for 3-4 mos. Urine Test Strip - LH upsurge < ovulation(ovulation predictor kits) Cervical Mucous Test(done @ home) • “Spinnbarkeit “=stretching of cervical mucous @ time of ovulation [d/t ^ estrogen]

4. How to Check for Ovulation… • Usually occurs on day 14 – 20 of menstrual cycle. Can be done with a regular cycle.*Count 14 days back from menses; accurate estimation of ovulation. • Calendar Method: keep diary of ~ 6 months of menses. To help locate fertile days using calendar method, you would teach: • Subtract 18 from shortest period and 11 from longest. (irregular cycle) • Range of days - “possibly” fertile.

5. Fallopian Tube Obstructions “Hysterosalpingography” - X-ray Imaging • Radiologic exam of fallopian tubes using radiopaque dye. • Catheter placed in cervix. Dye passes through filling uterus & fallopian tubes. • Structures/adhesions in uterus/tubes & tube patency assessed • Dye “blows out” tubes – clears obstruction; infertility resolved.

6. Hysteroscopy – visual inspection of uterus • hysteroscope: thin, hollow, lighted tube through cervix. Allows direct inspection of uterus. FU procedure to hysterosalpinography if abnormalities found. • CO2/saline used. • Diagnostic (local) or Operative (IV sedation) Surgical Evaluation: (general) Laparoscopy – insertion of thin, hollow, lighted tube thru incision made below umbilicus. CO2 gas inflates cavity. • Examines fallopian tubes & ovaries; checks distance between ovaries & tubes; if distance too great, ovum can’t enter tube. Remove growths (fibroids, masses, polyps, scar tissue) TL, ectopic pregnancy, hysterectomy. • Video camera used

7. Frequent Initial tests are: • Semen Analysis • Basal Body Temp.[graph temp.] • Sperm Penetration Assay [penetration ability] • Post-coital Test • Endometrial Bx. [assess level of estrogen & proges.] Other Fertility Procedures: • Meds: Clomid, Serophene (^ ovulation) • Increasing sperm count (abstinence 7-10 days) • Myomectomy (fibroids) • Tx vaginal infections (trichomoniasis, yeast, bacterial vaginosis) • Artificial Insemination (insert sperm into uterus/cervix) • In vitro fertilization (IVF): fertilize ovum w. sperm in lab & reinsert (~ 40 hrs). Removed by laparoscopy.

8. Alternatives to Childbirth: • Child-free living – allows for freedom, travel, careers, etc. • Adoption – may take long time, costly • Surrogate Motherhood – complicated legal & ethical issues may develop (woman may use own eggs or donated ova/sperm) 15% infertility cases in USA: Approx. 40% d/t male factors: • 1/2 of these irreversibly infertile. Others treatable Approx. 60% d/t female factors: • ~ 20% - 30% - ovulatory failure (hormonal) • ~ 20% - 40% - tubal, uterine, vaginal problems (blocked tube, fibroids, endometriosis , PID, etc.)

9. Endocrine Problems – Normal hormone activity needed for ovulation & development of healthy endometrium. • Any dysfunction of pituitary, thyroid, adrenals, pancreas & ovaries can alter ovulation. Uncontrolled DM may lead to recurrent miscarriage. ex. PCOS • Hypo or hyperthyroidism also problem. • Attempt to correct disorder Structural Disorders • Bicornate uterus; 2 horns. DES exposure. May need IVF. • Uterine Fibroids - removed with myomectomy or • May cause ↑ bleeding & prevent conception. May need hysterectomy

10. II. Male Factors Primary Causes of Male Infertility: Impaired sperm production/mobility/delivery; Testosterone deficiency (hypogonadism). Can be congenital or acquired. Problems in Sperm Production • Average # deposited is 70 million/ml in 2-6 ml. • Sperm count 20 million or less in 2-6 ml. suggests inadequate production. Causes: • Infections - HPV, gonorrhea, chlamydia, epididymitis, testicular inflammation (orchitis) [mumps as adult] • High fever from prolonged elevation of scrotal temperature; can cause irreversible infertility if before puberty • Diseases (cystic fibrosis, sickle cell anemia); Testicular Cancer • Testosterone deficiency - disorder in hypothalamic-pituitary-gonadal axis . • Testosterone production ^ rapidly with puberty & decreases > age 50. • Men with obesity, diabetes, HTN may be 2X as likely to have low testosterone levels.

11. Continued: Mechanical Factors: Variocele - varicose vein in spermatic cord. Blood does not cool - poor spermatogenesis. “Variocele Ligation” – improves sperm motility; not useful if sperm count < 10 mill/ml. Undescended Testicles (Cryptorchism) Correct with surgery. • If testicles stay in abdominal cavity during puberty (irreversible) • Absence of one/both testicles (anorchism) • Injury/testicular trauma - trigger immune response (antibodies) impairs sperm: can’t swim thru cervical mucus or penetrate ovum. • Environmental Influences: Exposure to radiation, chemicals, chemotherapy. Excessive smoking & ETOH, Drugs (anti-hypertensives & marijuana), DES exposure; Malnutrition, stress, hot tubs.

12. Problems with Sperm Mobility – Greater than 60% of sperm per ejaculate should be motile for effective fertility. Factors that may affect mobility: • Decreased Testosterone • Infection (gonorrhea, chlamydia) • Prostate Disease Problems with Sperm Transport: • Obstruction d/t scar tissue; secondary to infections [gonorrhea], injury to Vas Deferens or Vasectomy. • Retrograde ejaculation: Impaired muscles/nerves in bladder . Semen flows backward into bladder. • > bladder surgery/congenital defect in urethra/bladder • Rare; no ejaculate @ orgasm. • Retrieve semen in urine [voided or by catheterization]. • Specimen buffered & sperm artificially inseminated. • Hypospadias – congenital - sperm not high enough in vagina. Corrected after birth.

13. III. Combined Problems [Male/Female] – Sexual technique, timing, immunologic responses. Sexual Technique/Timing - Provide counseling on: • Position: Female on back with knees flexed for 10-15 min. • Fertility best if intercourse timed around ovulation. • ~ 14 days < onset of next menses. • Infrequent intercourse may lower sperm motility. • Frequent : may lower # mature sperm. Immunologic Factors • Women: antibodies against partner’s sperm (condoms for 6 mos) • Men: autoimmune response to own sperm (steroids for sev. mos)

14. H & P: Both partners • Past/Present Health, Family, Social, Sexual, Reproductive, Risk factors, Illnesses, immunizations, allergies, hospitalizations, accidents, injuries, medications, habits. • Support systems, occupational, educational, financial status. • How long attempting pregnancy? Review of Systems (ROS): Both Partners • Factors Significant for Both Partners: Exposure to radiation/toxic substances (lead); drugs, alcohol, marijuana, antihypertensives; STI’s; Maternal DES (diethylstilbestrol) exposure. PE of both partners

15. Management of Female Infertility Infections: Terazol (yeast); Metronidazole (BV, trich) Endometriosis: Danazol (Danocrine) – suppresses ovulation, FSH/ LH, & menstruation. Stops endometrial tissue growth. Side effects: wt. gain, hot flashes After stopping med. menses resumes 1-6 wks. OR… • Oral contraceptives continuously to suppress ovulation & tx endometriosis. • Surgical removal – for moderate to severe disease [laparoscopy] Cervical Problems • Estrogen Therapy – before ovulation for few months to enhance quality/quantity of cervical mucous. • Cryosurgery – freeze surface of cervix; or recurrent cervicitis. Endocrine Problems – Ex: Hypothyroid – replacement therapy [Synthroid] Hyperthroid – surgery, radioiodine, meds. Fallopian Tube Problems - Infections, adhesions, endometriosis. • Tx infections: Terazol, Metronidazole • Hysterosalpingogram may unblock tubes (3%) with procedure. • Lysis and excision of adhesions - with microsurgery. CO2 laser used for tubal occlusion.

16. Management of Male Infertility Lifestyle Changes – Avoid heat sources, radiation/chemicals, ETOH/drugs, tobacco. Hormone Tx – Clomid or testosterone may ^ sperm count. Artificial Insemination: If above fails, artificial insemination with partner’s sperm. • Also done when cervical environment hostile to sperm. • Sperm are in highest concentration and most motile in 1st few drops of semen; ejaculate is split and 1st fraction saved. • Multiple first fraction split ejaculates combined & inseminated. Impotency – failure to have erection. Can occur during infertility (need to perform). Supportive, non-judgmental atmosphere with reassurance - may be temporary. Counseling (high school years) - ^ drug/alcohol use occurs.

17. Newer Techniques in Managing Infertility In Vitro Fertilization (IVF) • Fertilization of mature ovum in lab & re-implantation of zygotes into uterus via laparoscopy. Fallopian tubes blocked in IVF candidates. Sperm sample must be normal. Costly. Success rate 20%. Not covered by insurance. Eggs can be frozen and fertilized later Gamete Intrafallopian Transfer (GIFT) Procedure • Mature oocytes aspirated from female. Oocytes loaded into catheter with 100,000 washed sperm; contents placed in fimbrated end of fallopian tube via laparoscopy. More expensive [surgical] • Dev. in 1984. Success rate 20-27%. • Advantage over IVF: entire procedure performed during one laparoscopy & eliminates 2-day lab incubation period. Avoids potential damage to zygotes.

18. ZIFT: Zygote Intrafallopian Transfer • Fertilized zygote/embryo transferred into fallopian tube instead of uterus. • Procedure also referred to as tubal embryo transfer • must have healthy tubes for this to work. Options for Infertile Couple • If treatments for infertility are unsuccessful, couple faced with several choices: Discontinue tx and remain childless OR….. • Adoption – Couple needs to resolve loss of biologic parenting first so that adoptive parenting can be positive experience. • Insemination with donor sperm.

19. Contraception • Motives for use & choice of method unique to individuals. • Range of alternatives discussed with clients so fully informed, satisfactory choice can be made. • Nurse should encourage male’s participation in selection and counseling. If uncomfortable/ unqualified in giving contraceptive information, provide referral. • Nurses who provide info. should be aware of all available methods; advantages/disadvantages.

20. Factors that Influence Contraceptive Choice • Individual’s stage in life cycle • Personal values • Religious, family, cultural background • Expense • Availability of bathroom facilities • Frequency of intercourse • Number of children desired • Risk of pregnancy couple is willing to accept • Presence of illness or physical problems • Level of comfort with body and its functions

21. Informed Consent • Client is informed about method. Discuss methods, benefits, risks, effectiveness, contraindications. Risks: Nurse discusses: • Side effects: weight gain, spotting, breast tenderness, nausea… • Inconvenience; partner dissatisfaction; condoms, ring Benefits: Non-contraceptive & contraceptive benefits • Therapeutic effects : reducing risk of PID; reduction in ovarian/uterine CA • Important to prevent preg.in very high risk women. Effectiveness – client’s main concern • Effectiveness Rate – in preventing pregnancy under ideal conditions • True Effectiveness Rate – decreases because of human error. ** All methods have advantages and disadvantages

22. SUMMARY OF CONTRACEPTIVE METHODS Basal Body Temperature (BBT) • Methodology: Client measures & records BBT on her calendar until ovulation can be predicted. • Action: Abstain from sex for several days before expected time of ovulation & for 3 days after ovulation. Rhythm Method (aka Calendar Method or Natural Family Planning • Methodology: Client uses calendar to calculate fertile/infertile phases of menstrual cycle. • Action: Abstain from sex during fertile period. Cervical Mucus Method (also called Ovulation Method or Billings Method) • Methodology: Client assesses cervical mucus for changes in wetness, color, & clearness throughout menstrual cycle until ovulation can be predicted by cond.of mucus. Spinnbarkeit • Action: Abstain from sex when mucus wet, clear, & stretchy.

23. Symptothermal Method • Client assesses & records information about primary signs (Cycle days, cervical mucus changes) & secondary signs ( ↑ libido, abdominal bloating) until ovulation can be predicted. • Abstain from sex for few days before expected ovulation & for 3 days after sex. Situational Contraceptives • Coitus Interruptus (Withdrawal): Male withdraws from vagina & ejaculates away from woman’s external genitalia. One of least reliable methods . Mechanical Contraceptives Male Condom: Condom covers penis & prevents sperm from entering birth canal. Man applies condom to erect penis before vulva/vaginal contact. Most popular method of male contraception. Female Condom: fits over cervix & covers part of external genitalia & base of man’s penis; prevents sperm from entering birth canal. Woman inserts condom before sex. Not popular.

24. Diaphragm • Methodology: Spermicide-filled diaphragm covers cervix preventing sperm from entering birth canal. • Woman fills diaphragm with spermicidal cream & inserts it into vagina before sex. • Must be left in place for 6 hours > sex; Re-fit with wt. gain or loss. Cervical Cap • Method: Cup-shaped device filled with spermicidal cream fits snugly over cervix; held in place by suction. Prevents sperm from entering birth canal. • Insert similar to diaphragm. • May be left in place for up to 48 hours. • Insert @ least 20 minutes before inter. & leave in @ least 4 hrs. after sex

25. Sponge (back on market) Douching • Method: Client douches with saline solution directly > intercourse. * Ineffective: not recommended. May facilitate conception by pushing sperm farther up birth canal. Creams, Jellies, Foams, Vaginal Film, Suppositories • Method: Substances destroy/immobilize sperm. Action: Client inserts into vagina before inter. • NOTE: Spermicides minimally effective when used alone; effectiveness ↑ when used with diaphragm, cervical cap, or condom • Leave in for 6 hours > sex.

26. Oral Contraceptives Combination estrogen [20mcg - 35mcg] & progesterone. [OC’s inhibit release of ovum & maintains cervical mucus that is hostile to sperm] • * Take family/medical hx • RISK: Thrombophlebitis. • Contraindicated in women with HTN, over 35 & smoking, hx breast, ovarian, uterine CA. • Take hormone pills for 21 days, takes placebo for 7 days, then restart next cycle of pills. To be effective - should be taken within 1 hour same time each day. Some antibiotics decrease OC effectiveness – use condoms. • No protection against STD’s – TEACH: consistent condom use. Double up dose next day if pill is missed.

27. OC CONT. • ^ risk of blood clots, esp. in smokers & women over 35 • breakthrough bleeding • Menstrual cycle & fertility return soon after stopping pill [99% of 187 women taking Lybrel for 1 year] within 90 days - recent study by Wyeth] Replacing Seasonal. (BTB 4x/year) Combination hormones other than Oral… • Vaginal Ring [once/month] • Ortho-Evra [patch] once/week

28. Long-Acting Progestin: Depo-Provera • Method: 150 mg. IM Injection - ceases ovulation & thickens cervical mucus to block sperm penetration. • Effective for 3 months. 4x/yr. Return of fertility delayed for ~9 mos. • Research shows: significant decrease in bone mass in all females especially teens. Counsel: • Calcium in diet; Weight bearing exercises. Use limited to 2-3 years; recommend IUD in monogamous couples; Bone density scan for continued use > 2-3 yrs. • Subdermal Implants (Norplant); no longer used in US; high rate of infection. • Implanon - single rod available. Good for 3 years; uses progestin only.

29. Intrauterine Device (IUD) • Method: IUD immobilizes sperm & impedes their progress from cervix through uterus to fallopian tubes. Also causes inflammatory response of endometrium; spermicidal effect. • IUD inserted by MD/NP into uterus, String visible at cervix. • Check for string > each menses. • Can perforate uterus “Mirena” has hormones; good for 5 yrs. “Copper T” [Paraguard] (10-12 years) • Multiple cases of STI’s [gonorrhea, chlamydia] can cause PID; recommended for monogamous couples only.

30. Emergency Contraception: Plan B (OTC – 18 yrs or older) Within 72 hours of unprotected sex. Does not cause abortion if implantation has occurred. Operative Sterilization Vasectomy • Method: Vas deferens on both sides of scrotum surgically severed, interrupting flow of sperm from epididymis. Often can’t be reversed d/t scarring. Semen will not contain sperm. Tubal Ligation • Method: Fallopian tubes are surgically severed preventing ovum & sperm from meeting. Can be reversed; costly. May not be covered by insurance. Reversal has ^ rate of ectopic preg.