Beruflich Dokumente
Kultur Dokumente
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.
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.
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
Motility :Spermatozoa should ascend through the cervix into the uterine cavity and
fallopian tube
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.
a) Erectile dysfunction.
C) Hypospadias.
b) Low-fructose content.
d) Undue viscosity.
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)
Tubal and peritoneal factors are responsible for about 30 to 40 percent of cases of
female infertility
These include:
2. Salpingitis
5. Tubal spasm.
UTERINE FACTORS:
These include factors that interfere with reception and nidation of fertilized ovum.
1. Uterine hyperplasia
3. Fibroids
4. Endometritis
5. Uterine synechiae
6. Congenital malformation
CERVICAL FACTORS
1. Chronic cervicitis
7. Pinhole os
VAGINAL FACTORS
2. Septum
3. Narrow introitus
COMBINED FACTORS:
These include presence of factors both in female and male factors causing infertility
INVESTIGATION OF FEMALE
HISTORY :
2.MEDICAL HISTORY :
4. MENSTRUAL HISTORY:
6.CONTRACEPTIVE PRACTICE:
7.SEXUAL PROBLEMS:
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).
4.HORMONE ESTIMATION:
A.SERUM PROGESTERONE:
B.SERUM LH:
C.SERUM ESTRADIOL :
This hormone attains peak rise approximately 24-36 hours prior to ovulation.
D. URINARY LH:
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:
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):
B. HSG has defined advantages over insufflation test . It can reveal any
abnormality in the uterus such as fibroid or synechiae .
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.
D. Ultrasound can follow the fluid through the tubes up to the peritoneal
cavity and in the pouch of Douglas.
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
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.
H. Psychological support should be offered as the couple may face significant stress and
sadness as the investigation and consultation progress.
General care:
Surgical treatment :
• In men, whose testicular biopsy shows normal spermatogenesis and obstruction is
suspected, vasoepididymostomy or vasovasostomy may help.
• Correction of hydrocele.
1. Ovulatory dysfunction :
• Induction of ovulation using drugs such as clomiphene citrate, letrozole , FSH, hcg
and GnRH.
2.Surgery :
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:
- Oligospermia or athenospermia
- 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.
4. The procedure may be repeated two to three times over a period of 2-3 days
INDICATION:
1.Untreatable azoospermia or athenospermia of husband.
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
5. Unexplained Infertility
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.
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.
TECHNIQUE:
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.
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 ICSI procedure involves a single sperm carefully injected into the center of an
egg using microneedle .
Surrogacy
Adoption
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.
10. Exercise maintains health and takes folic acid and supplements if prescribed.
NURSING DIAGNOSIS:
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