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SEVA MANDAL EDUCATION SOCIETY COLLEGE OF

NUSING
SUBJECT: MIDWIFERY AND OBSTETRICAL
NURSING
SEMINAR
ON
INFERTILITY

SUBMITTED TO:
MRS.NIKHITA BHONSALE
CLINICAL INSTRUCTOR

SUBMITTED BY:
MS. MANISHA.M.YADAV
FINAL YEAR BASIC BSc NURSING
Introduction
 Infertility rate is high in female as compare to male.

 Male about 30-40%, female about 40-55%, Unknown 10%.

Definition
Failure to conceive after regular unprotected sexual intercourse for two year in the absence of
known reproductive pathology – The National Institute for Clinical Excellence [NICE].

SUBFERTILITY
 Subfertility refers to a state in which a couple has tried unsuccessfully to have a child
for a year or more.

 The term unfertile means less fertile than a regular couple

TYPES OF INFERTILITY

Types
Primary Second
Infertili ary
indicates
Infertili
ty difficulty
ty
conceiving after
It denotes those already having
patients who conceived (and
have never either carried the
conceived. pregnancy to
term or had a
miscarriage)
.
INCIDENCE
 Generally, worldwide it is estimated that one in seven couple have problems
conceiving 80 % of couple achieve conception, if they so desire within one year of
having (4 to 5 times a week).Another 10 percent will achieve the object by the end of
second year . About 10 percent remain infertile by the end of 3rd year

Factors required for fertility (Male and Female)


 Healthy spermatozoa should be deposited high in the vagina at or near the cervix.

 Capacitating and acrosome reaction: spermatozoa should undergo changes and


acquire motility in cervical canal.

 Motility :Spermatozoa should ascend through the cervix into the uterine cavity and
fallopian tube

 a) Congenital: Undescended testes are a congenital condition in which


spermatogenesis is depressed. VA's deferens is absent bilaterally in 1%-2% of such
men.

 b) Hypospadias causes failure to deposit sperm high in the vagina .In kartagener
syndrome (autosomal disease),there is loss of ciliary function and sperm motility.

 c) Thermal factor : The scrotal temperature has to be 1°F-2°F less than the body
temperature. It is raised in condition such as varicocele, big hydrocele or filariasis.
Other causes are using tight undergarment or working in hot atmosphere.

 d)Infection: Mumps orchids after puberty may permanently damage spermatogenesis .


In chronic systemic illnesses like bronchiectasis , the quality of sperm is adversely
affected . infection of the seminal seminal vesicles or prostate depresses sperm count.

 e)Gonadotrophin suppression: This happens chronic debilitating diseases,


malnutrition, heavy smoking and with high alcoholic consumption.

 f)Endocrine factor: Follicles stimulating hormone(FSH) level is seen raised in


idiopathic testicular failure . Hypoprolactinemia is associated with impotence.

 g)Loss of sperm motality (asthenozoospermia and abnormal sperm morphology are


seen in some males).

 h)Genetic: common chromosomal abnormality in azoospermic male is Kleinfelter's


syndrome (47,XXY).

 i)Iatrogenic: Radiation ,cytotoxic drug nitrofurantoin , cimetidine , Beta blockers,


antihypertensive, anti- convulsanats and antidepressant drugs are likely to hinder
spermatogenesis.
2 .Obstruction of the efferent ducts : The efferent ducts may be obstructed by
Gonococcal or tubercular infection. surgical trauma during vasectomy or harniorraphy
may lead to obstruction

3 . Failure to deposit sperm high in the vagina(coital problems):

 a) Erectile dysfunction.

 b) Ejaculatory defects such as premature, retrograde or absence of ejaculation.

 C) Hypospadias.

4.Errors in seminal fluid:

 a) Unusually high or low volume of ejaculate(normal volume is 2ml or more).

 b) Low-fructose content.

 c) High uproar a gland in content.

d) Undue viscosity.

Causes of female infertility

 OVERIAN FACTOR :

1. Anovulation or Oligo-ovulation:
ovarian activity depends on gonadotrophins which are related to the release of GnRH
from hypothalamus( hypothalamopituitary ovarian axis)

Disturbance of these may result in anovulation , oligomenoorrhea or even


amenorrhea. In these conditions there is inadequate growth and function of the corpus
luteum.

TUBAL AND PERITONEAL FACTORS

Tubal and peritoneal factors are responsible for about 30 to 40 percent of cases of
female infertility

These include:

1. Previous tubal surgery or sterilization

2. Salpingitis

3. Tubal or peritoneal endometriosis

4. Polyps within the lumen

5. Tubal spasm.
UTERINE FACTORS:

These include factors that interfere with reception and nidation of fertilized ovum.

1. Uterine hyperplasia

2. Inadequate secretary endometrium

3. Fibroids

4. Endometritis

5. Uterine synechiae

6. Congenital malformation

CERVICAL FACTORS

1. Chronic cervicitis

2. Presence of antisperm antibodies

3. Congenital elongation of cervix

4. Second degree uterine prolapse

5. Acute retroversion of uterus

6. Occlusion of cervical canal with polyp

7. Pinhole os

8. Scanty vaginal mucus

9. Abnormal constituents in the mucus.

VAGINAL FACTORS

1. Atresia (partial or complete)

2. Septum

3. Narrow introitus

COMBINED FACTORS:

These include presence of factors both in female and male factors causing infertility

1. Age of wife beyond 35 years and advancing age in men .

2. anxiety and apprehension

3. use of lubricants during intercourse which may be spermicidal.


4. immunological factors.

RISK FACTOR OF INFERTILITY

INVESTIGATION OF FEMALE

 HISTORY :

1.Age , duration of marriage :

History of previous marriage with proven infertility if any.

2.MEDICAL HISTORY :

Tuberculosis, STD, Pelvic inflammatory disease , Diabetes.


3.SURGICAL HISTORY :

Abdominal or pelvic surgery that can cause peritubal adhesions.

4. MENSTRUAL HISTORY:

Hypo menorrhea or oligomenorrhea that are associated with


hypothalamopituitary ovarian axis which may be either primary or
secondary to adrenal or thyroid dysfunction.

5.PREVIOUS OBSTETRIC HISTORY:

In the case of secondary infertility , History of previous pregnancies


,interval , premature rupture of membranes or puerperal sepsis are
taken.

6.CONTRACEPTIVE PRACTICE:

Use of IUCD that have chance to produce PID

7.SEXUAL PROBLEMS:

Dyspareunia and loss of libido.

 EXAMINATIONS
 General examination:
Obesity or marked reduction in weight , abnormal distribution
of hair and underdevelopment od secondary sex
characteristics.
 SYESTEMIC EXAMINATION:
Hypertension, Organic heart disease , chronic renal lesion or
Endocrinopathies.
 GYNECOLOGIC EXAMINATION :
To look for Adequacy of hymeneals opening, evidence of
vaginal infection, undue elongation of cervix , uterine size ,
position and mobility.
 SPECULUM EXAMINATION :
For presence of cervical discharge, which if present needs to be
tested for infection.
 DIAGNOSTIC EVALUATION
1. MENSTRUAL HISTORY: look for evidences of ovulation such as :
A. Regular, normal menstrual loss between the ages of 20 and 35.
B. Mid-menstrual bleeding (Spotting) or pain.
C. Features of primary dysmenorrheal or premenstrual syndrome (PMS).

2.BASAL BODY TEMPERATURE (BBT):


A. 1.Patient is instructed to take and record body temperature daily on waking in the
morning , before rising out of bed.
B. 2.Maintenance of BBT chart helps in determining ovulation and timing of postcoital
test , endometrial biopsy , cervical mucus or vaginal cytology test for ovulation.it also
helps the couple to determines the most fertile period , if the cycle is regular.

3.CERVICAL MUCUS STUDY:


Alteration of the physiochemical properties of the cervical mucus occurs due to the effect of
estrogen and progesterone.

4.HORMONE ESTIMATION:

A.SERUM PROGESTERONE:

Estimation on day 8 and 21 days of cycle.An increase in value from 1 mg/ml


to greater than 6 mg/ml suggests ovulation.

B.SERUM LH:

Daily estimation of serum LH at Midcycle can detect LH surge. ovulation


occurs about 34 -36 hours.

C.SERUM ESTRADIOL :

This hormone attains peak rise approximately 24-36 hours prior to ovulation.

D. URINARY LH:

Ovulation usually occurs within14-24 hours of detection of urine LH surge and


almost always within 48 hours.

5.ENDOMETRIAL BIOPSY:

Biopsy is done on 21st to 23rd day of the cycle.(If cycle is irregular , it is done
within 24 hours of the periods).Evidence of secretary activity of the endometrial
glands in the second half of cycle gives the diagnosis of ovulation.
6.SONOGRAPHY:

Serial sonography during midcycle can precisely measure the Grafian follicle
just prior to ovulation.(18- 20mm) The features of recent ovulation are
collapsed follicle and fluid in the pouch of Douglas.

7.LAPAROSCOPY:

Laparoscopy visualization of recent corpus luteum or detection of the ovum


from the aspirated peritoneal fluid to the pouch of Douglas is the direct
evidence of ovulation.

8.INSUFFLATION TEST (RUBIN'S TEST) :

It is done to see the patency of fallopian tubes.it is done by pushing air or


carbon dioxide under-pressure through the cervical canal . If the tubes are patent
,air reaches the peritoneal cavity.it is done in the postmenstrual period at least 2
days after stoppage of menstrual bleeding.

 Positive findings include:

a. Fall in the pressure when raised beyond 120 mm Hg.

b. Hissing sound heard on auscultation on either iliac Fossa.

C. Shoulder pain experienced by the patient due to irritation of diaphragm by


air.

The procedure should not be done in the presence of pelvic infection. In about
one third of cases , the hence not very reliable.

9.Hysterosalpingography( HSG):

A. In this test , instead of air or carbon dioxide , dye is introduced


transcervically . The test is done in the postmenstrual phase, 2 days after
the stoppage of menstruation.

B. HSG has defined advantages over insufflation test . It can reveal any
abnormality in the uterus such as fibroid or synechiae .

C. Disadvantage of HSG is radiation risk.


10.LAPAROSCOPIC CHROMOTUBATION:

A. This is an invasive investigation and hence performed only after male


factors and ovulation function have been found normal or corrected.

B. It also helps in the detections along with tubal patency.

11.SONOSALPINGOGRAPHY:

A. This test involves a slow injection of Physiological saline into the uterine
cavity using a pediatric Foley's catheter.

B. The catheter balloon is inflated at the level of the cervix to prevent fluid
leak.

C. Ultrasonography of the uterus and fallopian tubes is then done.

D. Ultrasound can follow the fluid through the tubes up to the peritoneal
cavity and in the pouch of Douglas.

DIAGNOSTIC TEST FOR MALE


Urine Analysis

Blood Examination

Karyotype

Immunological Test

Semen analysis

Vasogram

Transrectal Ultrasound

Testicular biopsy

Management of infertility
Management of infertility or subfertility would depend upon the cause identified,
duration and age of the couple, especially the female

General instructions :

When minor defects are detected in both the husband and wife, each of which alone
could not cause infertility, but in combination they decrease the fertility potential, the
faults should be treated simultaneously :
A. Body weight : overweight or under weight of any partner should be adequately dealt
with to obtain an optimal body weight

B. Smoking and alcohol :Excess smoking or alcohol consumption to be avoided.

C. Ideal coital frequency : Intercourse on multiple days during the fertile window
period, which includes the five preceding and the day of anticipated ovulation should
be reviewed with the couple.

D. Use of the home fertility monitor and checking of vaginal mucus discharge to
determine the optimal timing of intercourse may be most helpful

E. Use of LH surge kit: Use of the kit can detect LH surge in urine by getting a deep
blue color of dipstick. The test performed between 12th and 16th day of regular cycle
and timed intercourse over 24-36 hours after the color change reasonably succeeds to
conception.

F. Avoidance of lubricants and douches to be stressed.

G. The use of fertility impairing meditation should be avoided by both Partners if


possible, e. g. hormones.

H. Psychological support should be offered as the couple may face significant stress and
sadness as the investigation and consultation progress.

Management Of Male Infertility


The treatment of male partner is indicated in extreme oligospermia , azoospermia ,
low volume ejaculate and impotency. Measure to improve spermatogenesis are
advised.

 General care:

 Improvement of general health :


• Reduction of weight in obese

• Avoidance of alcohol and heavy smoking

• Avoidance of tight and warm undergarment

• Avoidance of occupation they may elevate testicular temperature.

 Avoiding medication that interfere with spermatogenesis such as:


• Cytotoxic drugs, nitrofurantoin , cimetidine, anticonvulsants, antidepressants and beta
blockers.
Medication to treat specific causes:
• Human chorionic gonadotropin (hCG) and human menopausal gonadotropin (hMG)
for hypogonadism.

• Dopamine agonist (cabergoline) for hyperprolactinemia and altered testosterone level


and to improve libido, and fertility.

• The GnRH therapy for hypogonadism.

• Clomiphene citrate to increase serum levels of FSH, LH and testosterone.

• Antibiotics for genital tract infections.

 Special treatment for causes identified such as:


• Intrauterine insemination (IUI).

• In vitro fertilization (IVF).

• intractoplasmic sperm injection (ICSL).

• Artificial insemination with donor (AID) sperm.

 Surgical treatment :
• In men, whose testicular biopsy shows normal spermatogenesis and obstruction is
suspected, vasoepididymostomy or vasovasostomy may help.

• Correction of hydrocele.

 Treatment for females is also according to the disorders identified :

1. Ovulatory dysfunction :
• Induction of ovulation using drugs such as clomiphene citrate, letrozole , FSH, hcg
and GnRH.

• Correction of biochemical abnormality : Metformin for hyperinsulinemia ,


dexamethasone for androgen excess, bromocriptine for prolactin excess.

• Substitution therapy : Thyroxin for hypothyroidism, antidiabetic drugs for diabetes


mellitus.

2.Surgery :

• Laparoscopic ovarian drilling (LOD) or laser vaporization for polycystic ovarian


syndrome (PCOS).

• Surgical removal of virilizing or functioning ovarian, or adrenal tumor.


• Tubotubal anastomosis for adhesion in tube.

• Cannulation and balloon tuboplasty for block in tube.

• Fimbrioplasty for financial adhesion.

• Adhesiolysis for separation or division of adhesion.

• Salpingostomy to create an opening in tube in a completely occluded tube.

MANGEMENT OF UNEXPLAINED INFERTILITY


Unexplained or persistent infertility refers to those couple who have undergone
complete basic infertility workup and in whom no abnormality has been detected and
still remains infertile.
The reported evidence is about 10% to 20%. About 60% to 70% of those couples
becomes pregnant within 3 years without any treatment
The recommended treatment for unexplained infertility is induction of ovulation ,
IUI , and Super ovulation combined with IUI.

ASSISTED REPRODUCTIVE TECHNONLGY:


ART encompasses all method used to achieve pregnancy by artificial or partially
artificial means it involves. Manipulation of gametes and embryo outside the body for
the treatment of infertility.

DIFFERNT TECHNIQUES OF ART:

1. Intrauterine insemination (IUI)


2. In vitro fertilization (IVF)and embryo transfer(ET)

3. Gametes intrafallopian transfer(GIFT)

4. Zygote intrafallopian transfer (ZIFT)

5. Intracytoplasmic sperm injection (ICSI)

1. INTRAUTERINE INSEMINATION:
Intrauterine insemination involves placing increased concentration of motile sperms
close to the fallopian tubes bypassing the endocervical canal which is abnormal. IUI
may be artificial insemination husband (AIH), AID or insemination with donor egg.

INDICATION:

.- Hostile cervical mucus


- Cervical stenosis

- Oligospermia or athenospermia

- Immune factor (Male or female)

-Male factor impotency or anatomical detfect,But normal ejaculate can be obtained.


Eg: Hypospadias

- Unexplained infertility.

Techinque:
1. About 3 ml of washed and concentrated sperms are injected through a flexible
polyethylene catheter within the uterine cavity around the time of ovulation.

2. The processed sperms for insemination should at least be 1 million.

3. Fertilizing Capacity of spermatozoa is 24-48 hours.

4. The procedure may be repeated two to three times over a period of 2-3 days

5. Generally, 4 to 6 cycles of Insemination with or without superovulation are


advised.

2. ARTIFICAL INSEMINATION DONOR:


When the semen of a donor is used for insemination, It is called artificial insemination
donor.

INDICATION:
1.Untreatable azoospermia or athenospermia of husband.

2. Genetic disease affecting spermatogenesis husband.

3. Rh-sensitization of the women.

TECHNIQUE:
The donor should be healthy and serologically and bacteriologically free from
venereal disease , human immunodeficiency virus(HIV)and hepatitis .The recipient
and donor must be matched for blood group and Rh Typing , either fresh or frozen
Semen is used.

About three to six cycles may be used for success . Insemination when
combined with superovulation enhance success rate . Two insemination 18-42 hours
after hCG administration give higher Result when compared to single insemination
after 36 hours.
ARTIFICIAL INSEMINATION HUSBAND(AIH):
An AIH is done for four cycles. The results are better, if combined with ovulation
induction for multiple ovulations.

INDICATIONS:
1.Oligospermia

2. Impotency

3. Premature ejaculation or retrograde ejaculation

4. Hypospadias.Antisperm antibodies in cervical mucus

5. Unexplained Infertility

6. X-Y Fractionation , Washing, Centrifugatiom and swim up methods are done.

TECHNIQUE:
Semen collection, washing, centrifugation and swim-up methods are done. Washed
and concentrated sperm is then placed in uterine cavity as in AID technique.

IN VITRO-FERTILIZATION(IVF) AND EMBRYO


TRANSFER(ET):
 Fertilization of an ovum outside the body is technique used when a women has
blocked fallopian tubes or some other impediment to the union of sperm and ovum in
the reproductive tract. The women are given hormone therapy causing a no of ova to
mature at the same time. Several of them are then removed from the ovary through a
laparoscope.

 The ova are mixed with spermatozoa from her spouse and incubated in a culture
medium until a blastocyst is formed. The blastocyst is then implanted in the mother's
Uterus and the pregnancy allowed continuing normally.

INDICATION:
- Tubal disease or block

- Endometriosis

- Cervical hostility

- Unexplained Infertility

- Ovarian failure
PATIENT SELECTION:
1. Age of women less than 35 years.

2. Presence of at least one functioning ovary

3. Normal seminogram for husband

4. Couple negative for HIV and hepatitis.

TECHNIQUE:

1.Induction of superovulation using drugs clomiphene citrate and GnRH.


2. Monitoring of follicular growth: This is done by cervical mucus study , sonographic
measurement of the follicle and serum astral estimation.

3.Ovum retrieval :

This is done either laparoscopic ally or vaginally.if vaginal route is used ,A small Needle is
inserted through the back of a vagina and guided via ultrasound into the ovarian follicle to
collect the fluid that contains the ova about 36 hours after hCG administration , but before
ovulation occurs.

4.Fertilization:

The sperm for insemination in vitro is prepared by the wash and swim technique .
Approximately 50,000 -100,000 Sperms are placed into the culture media containing the
oocyte within 4-6 hours of retrieval .

5.Embryo transfer:

The fertilized ova at the four to eight cell stages are placed into the uterian cavity close to the
fundus about 48-72 hours later through a fine flexible tube transcervically . Not more than
three embryos are transferred per cycle to minimize multiple pregnancies.

Gamete Intrafallopian Transfer(GIFT)


 In this procedure , both the sperm and the unfertilized oocytes are transferred into the
fallopian tubes using laparoscopy following trans vaginal ovum retrieval .
Fertilization is then achieved in vivo.

 The result is poor in male factor abnormality

 Superovulation is done as in IVF.

 The semen is washed by 'swim up' Technique and the most fertile fraction of the
sperm is obtained and used for transfer
ZYGOTE INTRAFALLOPIAN TRANSFER(ZIFT)
• In ZIFT , egg cell are removed from the women's ovaries and fertilized in the
laboratory . The resulting zygote is then placed in the fallopian tube following one
day in vitro fertilization through laparoscope or through a uterine opening under
ultrasonic are present.

• The technique is s suitable alternative of GIFT.GIFT procedure are avoided when


tubal factors of infertility are present.

Intracytoplasmic sperm injection (ICSI)


• Intracytoplasmic sperm injection method is beneficial in the case of male factor
infertility where the sperm counts are very low or failed fertilization with previous
IVF attempts.

• The ICSI procedure involves a single sperm carefully injected into the center of an
egg using microneedle .

• Sperm is retrieved from the ejaculate or by testicular sperm extraction (TESE) or by


microsurgical epididymal sperm aspiration.

• Indications are azoospermia , severe oligospermia , sperm antibodies and obstruction


of afferent duct system and failure of IVF.

Surrogacy

Adoption

PROGNOSIS OF ARTIFICAL REPRODUCTIVE METHODS


• The pregnancy rate within 2 years after the start of investigation ranges from 30% to
40%.The rate is higher ,If AID cases are include. However , if pregnancy occurs ,
there is two-fold increased chance of abortion , five times ectopic pregnancy and the
perinatal mortality doubles.

ROLE OF NURSE IN MANAGEMENT OF INFERTILITY:


 1. Assessing, educating and counseling in addition to therapeutic assistance as they
undergo tests and procedures.

 2. When couple presents with concerns about the infertility , it is important for the
nurse to understand that men and women are very concerned and possibly emotionally
fragile.
 3. Before or even beginning the medical aspect of care is important to understand and
assist the couple to understand and assist the couple to understanding their motivation
for pregnancy and to offer support.

 4 The couple should understand and accept that evaluation and treatment for infertility
will be stressful and will involve both partners throughout the process.

 5. important to meet couple together.

 6. Taking an details such as family , Medical ,Previous treatment or anything related


to health.

 7. Nursing intervention include assisting in reducing stress , encouraging


cooperation ,protecting , privacy and fostering understanding.

 8. Educated the couple to avoid smoking, Drinking during treatment.

 9. Take proper diet.

 10. Exercise maintains health and takes folic acid and supplements if prescribed.

NURSING DIAGNOSIS:

 Fear related to possible outcome of subfertility studies.

 Situational low self esteem related to the apparent inability to conceive.

 Anxiety related to what the process of fertility testing will entail.

 Deficient knowledge related to failure to conceive or sustain a pregnancy.

 Powerlessness related to repeated unsuccessful attempts at achieving


conception.

 Hopelessness related to perception of no viable alternatives to usual


conception.

 Fear related to possible outcome of subfertility studies.

 Situational low self esteem related to the apparent inability to conceive.

 Anxiety related to what the process of fertility testing will entail.

 Deficient knowledge related to failure to conceive or sustain a pregnancy.

 Powerlessness related to repeated unsuccessful attempts at achieving


conception.
 Hopelessness related to perception of no viable alternatives to usual
conception.

RESEARCH

This pie diagram shows that infertility rate in male and female. Where male factor account
26% infertility and in female uterine factors is 2.2%, tubal factor is 27.9%, endometriosis
14.8%, ovulary dysfunction 12.6% , unexplained cause is 8.5% and other causes percentage
is 8%.
Bibliography
 Dutta D.C, Textbook of Gynaecology, 3rd edition

 Fraser Diane M & Myles Cooper Margaret A, Textbook for Midwives, 5th edition

 Lippin Cott williams & Wilkins, Meternal & child health, 7th edition 2014

 Littleton, Lynna Y & Engebreston John C, Maternity Nursing Care, 1st Indian Reprint
2017

 Henderson chris & Macdonald sue, Mayes’s Midwifery, A textbook for Midwives,
13th edition

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