N230Mod15-17 209

Module 15
Advances in Diagnosis and

Management of Infertility
Teresita I. Barcelo, R.N., Ph.D
S ince the first successful vaginal artificial in-

semination with the husband’s semen done
by Hunter in the 18th century, the management
Objectives
of infertility has come a long way. Do you remem-
ber Louise Brown? She was the world’s first baby After studying this module, you
to be born using in-vitro fertilization with embryo should be able to:
transfer (IVF-ET), done in 1978 by Edwards and
Stytstre. 1. Explain the mechanism and
process of the new technologies
The aim of medically assisted conception is to in determining the causes of
overcome the barriers preventing spermatozoa infertility in females;
from encountering oocytes in infertile couples. To 2. Explain the interpretation of the
accomplish this objective, numerous researches results of the new technologies
in this area have been done particularly in the in determining the cause of
last three decades. It is therefore important for infertility in females;
you who would be an MCN specialist to be fa- 3. Explain the various assisted
miliar with these advances in infertility detection reproductive technologies in
and management. managing infertility in both
males and females;
4. Analyze the nursing implica-
Diagnostic Procedures tions of the new technologies of
determining causes and man-
for Infertility agement of infertility; and
5. Write a report on the current
Optimal management of the infertile female status of infertility diagnosis and
requires accurate diagnosis of the cause and ap- management in the country
propriate treatment, as pregnancy can now be based on an interview of a local
practitioner.
438 N230 Primary Care of Women
achieved in the majority of patients. According to the World Health Or-

ganization, the main cause of infertility both in developed and develop-
ing countries are infections with incidence varying from 28% to 65% in
different centers. Figures 15-1 and 15-2 show the common specific causes
of infertility in women in Sub-Saharan Africa and developed countries.
Female cases of infertility has a higher incidence than that of males in

developing countries (31% female and 22% male cases) and developed
countries (37% female and 8% male cases).
In women, the most common cause of infertility is disease of the fallopian

tubes caused by infection. The most common bacteria that are transmit-
ted sexually and cause pelvic inflammatory disease are chlamydia
trachomatis and the gonococcus, neisseria gonorrhea. Pelvic infection with
these organisms can lead to adhesions involving the fallopian tubes and
ovaries.
Ovulatory disorders also rank high as a cause of infertility (17.9% in de-

veloping countries and 24.8% in developed countries). One important
aspect about fertility in a woman is that she is ovulating. The methods of
detecting ovulation discussed in Module 13 and the natural family plan-
ning methods presented in Module 14 can be used to determine fertility or
infertility in women.
SAQ 15-1
Look at Figure 15-1 and Figure 15-2 on the next page. These two
figures illustrate the common causes of infertility in women in the
Sub-Saharan African Countries and in developed countries.
In the table below, fill in the data needed to complete the matrix.
Sub-Saharan African Developed

Causes % Rank % Rank
Bilateral Tubal Occlusion 41.9 1 10.6 3

___________________ _____ 2 _____ _____
Pelvic Adhesion _____ 3 12.4 _____
___________________ _____ 4 _____ _____
___________________ _____ 5 _____ _____
___________________ _____ 6 _____ _____
Bilateral Tubal Occlusion 0.9 7 5.7 7
___________________ _____ 8 _____ _____
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Module 15 439
ia
em
is
os
na
1% etri
4% ti
ac
m
ol
do
l
pr
ba
En
er
tu ies
yp
d t
ire ali
H
qu rm
Ac bno 10%
a
s
io n
es
adh
ic %
P elv 11
Bilateral tubal occlusion

42%
No d
em o
ns
caus trable
e
14%
Occulatory disorders
18%
Figure 15-1. Distribution of most common specific

causes of infertility in women in Sub-Saharan
is
ios
et r n
om % sio
En
d 6 c clu
Pe
lvic lo
a
tub %
ad ra l 11
12 hesi ate
% on
s B il
Ovulatory disorders No demonstrable

25% cause
28%
H
yp
% litie al
er
11 ma tub
s
pr 7%
ol
r d
no ire
ac
ab qu
tin
Ac
ae
m
ia
Figure 15-2. Distribution of most common specific

causes of infertility in women in developed countries
(Source: WHO Recent Advances in Medically Assisted Conception
Report of a WHO Scientific Group. Geneva, 1992, p. 4.)
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Blood test for chlamydial infection

WHO studies found in the 1990-1991 Biennial Report reveal that a single
episode of chlamydial infection can cause tubal blockage in 17% of women.
While this test for the presence of chlamydia does not directly test the
presence of infertility in a man or woman, it can detect the presence of the
infection which is often sub-clinical in nature. Hence, if the infection is
detected early, appropriate management of the infection can be done to
prevent blocking of the tubes.
It is difficult to culture chlamydia. Thus, the research activities of WHO

include the development of a simple diagnostic blood test which is spe-
cific for acute chlamydial infection of the genital tract. The test is based on
the detection of a secretory immunoglobulin A (sIgA) antibody which is
specific to chlamydia. A similar test is being developed for men, where
urine samples are used to detect chlamydial urethritis. This condition is
asymptomatic in up to one-third of the cases and infected men can act as
a reservoir of chlamydial infection for their sexual partners.
Laparoscopy with hydratubation

To determine if the problem of infertility is due to tubal obstruction, the
newer method used is laparoscopy with hydratubation using methylene
blue or indigo carmine as contrast medium. Laparoscopy enables the
whole pelvic region to be visualized so that extratubal adhesions, which
are not diagnosed at the time of hysterosalpingogram, can be visualized.
It also enables the physician to assess the extent of the tubal disease and
determine if there are other pelvic pathology such as fibroids or endometrio-
sis. However, laparoscopy cannot assess the uterine cavity.
Hysteroscopy
If the suspected cause of infertility in the female is intra-uterine, a hyste-
roscopy is done. This technique is more accurate in evaluating intra-cavi-
tary lesions or pathology.
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Module 15 441
Magnetic Resonance Imaging (MRI)

Magnetic Resonance Imaging (MRI) has been found useful in evaluating
various conditions associated with infertility in females like differentia-
tion of a bicornuate uterus from a separate one; accurate localization of
leiomyomas and differentiating it from another tumor, adenomyosis; and
detect endometriosis. The use of MRI which is non-invasive can reduce
the use of more invasive procedures such as laparoscopy.
Postcoital test
To detect if there are abnormalities of the cervical mucus, a postcoital test
is performed just before the mid-cycle. Where the timing of mid-cycle is
difficult, ethinylestradiol is given in a dosage of 100 ug per day for ap-
proximately seven days from day 5 of the cycle, and the post coital test is
performed on the seventh day of the treatment.
Where the postcoital test shows some abnormality (i.e., less than 5 motile
sperm per high power field), a formal sperm penetration test shoud be
performed in the laboratory (Kremer test). Where this test shows also some
abnormality, anti-sperm antibodies should be done in the mucus and in
the serum of the woman.
Chlamydial Vaccine Research

Chlamydia infection of the genital tract is probably the most common of
tubal obstruction resulting in infertility, but it is the most difficult to diag-
nose and treat. In fact, it often goes undiagnosed. Large scale vaccination
against the chlamydial organism offers the possibility of preventing or
lessening the severity of pelvic chlamydial infection.
The major protein in the outer membrane of the organism of chlamydia

trachomatis has been isolated and its chemical structure determined. The
sites on the molecule where the antibody binds have been identified and a
prototype vaccine has been tested in an animal model for chlamydial pel-
vic infection. Research has started on the vaccine delivery system as this
will be all-important in ensuring that the optimal dose of the vaccine is
delivered.
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SAQ 15-2
Put a check (3) in the proper column if each diagnostic procedure
is appropriate for the conditions given in the first column.
Diagnostic Procedure
Condition Laparoscopy Hysteroscopy MRI
with
hydratubation
1. Obstructed __________ __________ __________

fallopian tube
2. Endometriosis __________ __________ __________
3. Pelvic adhesions __________ __________ __________
4. Ovulatory disorders __________ __________ __________
5. Uterine Septum __________ __________ __________
Now, pause for a while and reflect on the text you have just read. Try to
make a brief summary in your own notes. After having gone through the
text on the diagnostic tests and preventive vaccine for chlamydia, you are
ready for the next text which deals with the trends in assisted reproduc-
tive technologies.
The next text is quite technical in nature, but if you are familiar with the
normal reproductive process, it shouldn’t be that difficult.
Management of Female Infertility

Induction of female fertility
The use of ovarian hormonal stimulation has been shown to provide greater
numbers of oocytes for fertilization and to maximize the yield of embryos
that can be transferred with consequent increased pregnancy rate.
Ovarian stimulation is done through the use of drugs like Clomiphene

Citrate combined with Human Chorionic Gonadotrophin (HCG) or Hu-
man Menopausal Hormone (HMG) or Follicle Stimulating Hormone (FSH).
While Clomiphene Citrate is the most common drug used, it has major
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Module 15 443
limitations. Two of these limitations are: inhibitions of endometrial devel-

opment as a result of anti-estrogenic activity so that implantation is im-
paired, and low yield of oocytes.
Bromocriptine mesylate is a potent dopamine receptor agonist that in-

hibits prolactin secretion and is indicated in the treatment of female infer-
tility associated with hyperprolactenemia. Bromocriptine has recently been
released for the induction of ovulation in patients with elevated prolactin
levels.
There are several methods that are used to monitor ovulation. These pa-
rameters include Basal Body Temperature (BBT), Billing’s method, moni-
toring blood levels of pre-ovulatory estrogen and mid-luteal phase proges-
terone level, and/or endometrial biopsy. You have already read about
these in previous module. This time you have to know the complications
of each procedure so that you may be able to anticipate interventions
needed by your clients.
A serious complication of ovarian stimulation is the formation of multiple

ovarian cysts, both follicular and luteal, associated with excess steroid
production, and ovarian enlargement. In mild cases, ascites, hydrotho-
rax, electrolyte imbalance, hemoconcentration, hypovolemia, oliguria and
thromboembolic phenomena may complicate the condition. The incidence
of severe hyperstimulation syndrome reported in a series of research pa-
pers since 1970 varied between 0.2% and 1.8%.
According to the Report of the WHO Scientific Group which met in Geneva
in 1990,the timing of the retrieval of the oocytes after a successful mul-
tiple follicular development triggered by drug stimulation is very impor-
tant to the success of using these oocytes for assisted reproductive tech-
nology. This time interval is selected to permit in-vivo oocyte maturation
on one hand, and to reduce the possibility of premature ovulation and
loss of the oocytes on the other. Retrieval of oocytes is done through
laparoscopy or through an ultrasonically guided probe by means of trans-
vaginal approach.
Now, let’s consider the non-pharmacologic interventions in female infer-

tility management.
Oocyte and embryo cryopreservation

The maturation and freezing of the oocyte are significant technologic
advancements of recent years. Oocyte freezing enables excess oocytes har-
vested in a stimulated ovulatory cycle to be preserved and offers possibil-
ity of repeating in-vitro fertilization with embryonic transfer in subse-
quent cycles without need for another ovarian stimulation.
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The maternal and perinatal risks of high multiple pregnancy following

transfer of more than four embryos are well documented, but the transfer
of only one embryo results in low pregnancy rates. Since several embryos
are fertilized and only one to four will be utilized the excess fertilized
embryos are used for research purposes (which is legally and ethically
unacceptable in many countries including the Philippines) or are frozen
(cryopreservation) and saved for future transfer.
Insemination of oocytes
Embryologists have developed various insemination techniques that in-
volve micro-manipulation of the gametes including partial zona dissec-
tion of the oocyte to assist penetration of the zona pellucida by the sperm.
Mechanical force as an acidic medium, maybe used to open the zona
pellucida to expose the oocyte to the spermatozoa.
Another approach involves the microinjection of a number of spermato-

zoa into the perivitelline space, the space between the oocyte membrane
and the zona pellucida. This technique of intra-cytoplasmic injection of
sperm into the oocyte eliminates the need of sperm to travel any distance
to the oocyte or penetrate any layer of the oocyte. This technique, which
has been used on a limited basis in Europe and North America, has far
ranging implications given that sperm do not necessarily have to be vi-
able, only their DNA need to be functional.
Assisted Reproductive Technologies (ART)

There are three assisted reproductive technologies already being done
nowadays. These are Gamete Intra-Fallopian Transfer Techniques, Zy-
gote Intra-Fallopian Transfer and Pro-Nuclear Stage Transfer.
Gamete Intra-Fallopian Transfer Techniques (GIFT)
The GIFT technique involves the recovery of ova by laparoscopy and the
transfer of gametes into the fallopian tubes during the same operation. In
general, up to three mature oocytes are loaded into a transfer catheter
with 100,000 to 200,000 washed sperm in 25-50 ml of culture medium.
The loaded catheter is inserted through the fimbrial orifice, usually to a
depth of 2-4 cm and its contents are gently discharged by means of an
attached tuberculin syringe. A higher pregnancy rate has been reported
when the gametes have been injected at a depth greater than 4cm. This
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Module 15 445
procedure is repeated in the opposite tube, if possible. Follicular fluid has

been advocated as an additive or substitute for culture medium, as it has
been shown to promote the acrosome reaction and improve the in-vitro
fertilization.
Zygote Intra-Fallopian Transfer (ZIFT)

and Pro-Nuclear Stage Transfer (PROST)
In 1986, Devroey et al., reported the occurrence of pregnancy after

translaparoscopic ZIFT in a patient with sperm antibodies. The develop-
ment of a safe and efficient procedure for trans-vaginal oocyte recovery
offered the possibility of obtaining oocytes at an outpatient clinic, in-vitro
insemination of the oocytes, and transfer of the cleaving embryos into the
fallopian tubes, using a technique similar to that used in GIFT.
Transferring the embryo at the pronuclear stage (PROST) has the advan-
tage that their exposure to laboratory conditions is minimized. It is also
possible to perform a transcervical/transuterine transfer of either gametes
or zygotes into the fallopian tube, as long as there is no underlying tubal
disease.
You may want to pause at this point and accomplish SAQ 15-3.
SAQ 15-1
Describe briefly the differences in technique of the following meth-
ods: GIFT, ZIFT and PROST.
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Efficacy of Assisted Reproductive Technologies (ART)
Questions have been raised regarding the efficacy of assisted reproduc-

tive technology (ART) if it leads to a pregnancy with multiple fetuses and
places each infant at risk for premature delivery and possible birth de-
fects. In an effort to address this issue, embryologists are attempting to
improve the culture media environments in which the embryo resides
between the time of oocyte insemination with sperm and transfer of a
viable embryo into the uterus.
Other improvements in ART includes assessment of the uterine environ-

ment through the ultrasound to determine the appropriate time to trans-
fer the zygote into the uterus. Assessment of the uterine environment also
may provide the opportunity to optimize the success of a clinical preg-
nancy. Doppler flow ultrasound is used to investigate and identify the
appropriate time to transfer an embryo. In addition, the identification of
the critical physiologic changes required by the endometrium at the time
of implantation is being investigated. This information will help in decid-
ing when and in which reproductive cycles to transfer an embryo.
Only about 65% of all pregnancies achieved by in-vitro fertilization have

resulted in live births. Spontaneous abortions, ectopic pregnancies and
multiple pregnancies have contributed to early and late pregnancy losses
and increased perinatal and mortality rates.
The incidence of spontaneous abortions following natural fertilization has

been commonly quoted as 10% of all pregnances. The spontaneous abor-
tion rate among pregnancies following induction of ovulation was found
to be 20% in patients treated with clomiphene citrate; while in pregnan-
cies following induction of ovulation with gonadotropin preparations,
the range is about 17-31%.
Ectopic or extra-uterine pregnancy is one of the major complications of

in-vitro fertilization-embryo transfer IVF-ET. The global data for 1987
according to WHO, show that the incidence was around 5%, far greater
than the 1% reported to spontaneous conceptions.
Heterotopic pregnancy (concomitant ectopic and intra-uterine pregnancy)

has been recognized as potentially serious hazard of IVF-ET and other
procedures. It has been reported after ovarian stimulation with clomi-
phene citrate and after gonadotropin treatment, as well as after IVF-ET
and GIFT.
The (WHO) world survey which was completed in 1987 showed a mul-
tiple pregnancy rate of 24.2% after IVF-ET or GIFT. Multiple pregnancy
rates are higher after GIFT than after IVF.
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Other problems associated with ART are high rate of perinatal mortality,
premature delivery and chromosomal aberrations. The perinatal mortal-
ity rates vary from one IVF registry to another, this maybe due to the use
of different definitions. The IVF data from Australia show a perinatal
mortality rate of 42 per 1000 as compared with 23 per 1000 in France.
Even with corrections made for multiple pregnancy and other factors,
IVF-ET and other procedures are associated with a rate of premature de-
livery of about twice the national average in the countries reported.
Chromosomal anomalies represent the major cause of embryonic loss

during the pre- and peri-implantation period. Of all pre-implantation
embryos resulting from IVF, 25-30% have chromosomal abnormality.
Treatment of Male Infertility
Hormonal and surgical treatment

The WHO Human Reproduction Research Program has undertaken two
studies on male infertility. One study investigated the effect of hormonal
treatment of oligozoospermic men who are treated with mesterolone.
Mesterolone is a form of male hormone testosterone that is thought to
stimulate indirectly sperm production by the testes. Another study inves-
tigated if surgical ligation of the varicose veins around the testes, a condi-
tion known as varicocele, will result in the man impregnating his partner
in the year following the operation.
Artificial insemination
Artificial insemination with the husband’s/partner’s sperm (AIH) or with
a donor (AID) is a technique used today if the male partner has problems
of infertility. A newer technique is intra-uterine insemination with se-
men washed with a special solution to increase the sperm concentration
and transport. This technique is particularly useful in couples with hostile
cervical mucus.
Artificial insemination with the husband’s/partner’s whole ejaculate is

effective, if the male, in an otherwise fertile couple, is unable to deposit
sperm into the woman’s vagina because of some psychologic or physi-
ologic factors like premature ejaculation, hypospadias or retrograde ejacu-
lation.
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Now, you have read the advances in assisted reproductive technologies

(ART). These discussions look all highly technical and you may wonder
what is the role of the nurse in all these seemingly “doctor-scientist” tech-
nologies. You should not forget that the recipient of all these advances is
still the human patient. Since nursing deals with the human response to
illness and medical technologies, then there is definitely a place for nurses
in all these “high-tech” where there is a need for “high touch.”
Nursing Implications
The nurse practitioner has several roles in infertility management: as health
educator and counselor, patient advocate, and as coordinator of all the
services and diagnostic procedures that the couple have to undergo.
The fields of human genetics and assisted reproductive technologies are

progressing rapidly. Nurses must keep abreast with the new knowledge
in these fields. Health care consumers have come to expect and respect
nurses’ role in the dissemination of health care education and counseling,
a role that cannot be appropriately fulfilled without current knowledge.
Nurses, by virtue of their practice role, will be asked by health care con-
sumers for assistance in the decisions they will have the opportunity to
consider. This role will become universal within nursing as scientific ad-
vances move access to high technology healh care into the primary health
setting.
The nurse as a coordinator of services

The role of the infertility nurse incorporates key elements that can facili-
tate a positive outcome. For example, the nurse may be responsible for the
overall coordination of the diagnostic procedures that the couple have to
undergo as well as the rigorous treatment for such conditions. She should
be sensitive to the feelings of the couple who may have to undergo rigid
regimen that will require strict compliance with activities like taking basal
body temperature, collecting urine samples at specified time, providing
semen on demand. This rigid behavioral regimen may create a feeling of
subjugation or “loss of control” in the couple.
The nurse as a counselor and health educator

The nurse should be prepared to provide emotional support to the infer-
tile couple and assist them to cope with the stresses created by the diag-
nostic tests or treatment. Any fertility test or treatment maybe emotion-
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Module 15 449
ally stressful because it is a reminder of the person’s fertility problem and

can have an impact on his or her sexual identity. Emotional effects of
infertility can lead to marital stress. This stress created is of special con-
cern to the infertility nurse whose main objective is to enhance fertility.
However, the stressful aspect of treatment may be counterproductive to
that aim. Studies have already shown a definite role of stress in decreas-
ing fertility.
Remaining sensitive to a patient’s need for supportive comments, reassur-

ance when side effects occur, and communication of the relationship of
each step to the goals of therapy are essential. The nurse should develop
and provide an instruction sheet to each patient when therapy is begun.
The infertility nurse should counsel the couple about the possibility of
non-success and implement the referral network at the appropriate time.
If the infertile couple achieves a pregnancy, the maternity nurse should
also be aware that the pregnancy is often a high risk one and thus she
needs to assist the couple to understand that a possible loss of the preg-
nancy can occur. On the other hand, some couples who have achieved a
pregnancy after being infertile may use denial as a coping mechanism to
protect themselves from the emotional trauma of another pregnancy loss.
However, the use of denial during pregnancy may decrease the identifi-
cation or early bonding with the child by the mother, altering the pattern
of internalizing maternal identity.
The nurse must be accessible to the couple. This access can be attained by
establishing a telephone call-in time, reserving time for couple counseling
session or questioning time or give instructions when the couple is sched-
uled for physical visit.
The nurse as a client advocate

The nurse is in a unique position to provide support to the couple who
may be having not only physiologic problems but also having psychologi-
cal difficulties accepting their condition. She can also get involved in the
architectural planning and creation of sensitive environmental settings in
treatment areas. For example, the placement of obstetrical patients and
infants in the same recovery room with women receiving treatment for
infertility may have adverse emotional effects on infertile couple during
recovery from major surgeries.
Finally, the nurse should be aware of the differing effects of infertility for
men and women. Women especially may feel incomplete and unfemi-
nine. To the minds of many Filipinos, if the couple fails to achieve preg-
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nancy, the fault is often attributed to the female. The nurse should in-
clude the husband in the decision-making, provide him also with sup-
port, and assess his feelings about infertility.
Activity 15-1
Make a written report of not more than 500 words on the status of
infertility diagnosis and treatment in the country based on your
interview and your supplementary readings of local professional
literature. Be prepared to share your report with your colleagues
during the study session/online discussion.
Discuss the feasibility of using the reproductive technologies pre-

sented in this module in our country today. To help you to form a
more empirically-based opinion on this topic, conduct an inter-
view of a gynecologist or obstetrician (preferably an infertility spe-
cialist). Find out the current status of infertility diagnosis and treat-
ment in the Philippine and what the success rate of the treatment
being used here in our country.
Summary
Infertility is a problem that affects couples in both developing and devel-
oped countries. The most common cause of infertility is infection and the
two common microorganisms causing these infections aer chlamydia
trachomatis and neisseria gonorrhea. These infections lead to tubal disor-
der which is the leading cause of infertility. The World Health Organiza-
tion is now investigating the use of chlamydia vaccine to prevent this
often asymptomatic and usually undiagnosed condition of chlamydia in-
fection. In order to detect tubal disorders, pelvic pathology such as fi-
broids and endometriosis, laparoscopy with hydratubation can be done.
To detect abnormalities of the cervical mucus, a post-coital test can be
done together with a sperm penetration test (Kremer test).
Assisted reproductive technologies (ART) have been developing rapidly.

These technologies have now improved on the artificial insemination tech-
nique and in-vitro fertilizaton technique. These are: gamete intra-fallo-
pian transfer (GIFT), zygote intra-fallopian transfer (ZIFT), and pro-nuclear
stage transfer (PROST).
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Module 15 451
These new tehnologies have a success rate of only 65% of IVF resulting in
live births. Some of the concomitant problems that go with ART that need
to be addressed seriously, especially because of their legal and ethical im-
plications are: high rate of spontaneous abortion, multiple pregnancies,
ectopic pregnancies, heterotopic pregnancies, and chromosomal aberra-
tions.
Some women have unovulatory cycles so that now the technique being
used is ovary stimulation to induce ovulation. These oocytes can now be
stored for future use through cryopreservation, a technique long been
used for sperm banking.
Artificial insemination has now been done outside of the female repro-
ductive tract and the oocytes are now being inseminated through micro-
manipulation of the gametes, i.e., intra-cytoplasmic injection of sperm
into the oocyte.
Male infertility is also being studied and two investigations along this line
are being conducted by WHO. One study is investigating the effect of
injecting mesterolone to oligosoospermic men to stimulate spematogenesis.
The other study is investigating the effect of surgical ligation of the varico-
cele in the tests to improve spermatogenesis.
The nurse needs to be knowledgeable regarding these advances in ART so

that she can provide correct and adequate information to her clients. The
major role of the infertility nurse are as educator, as counselor, as patient
advocate, and as coordinator of services.
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Answers to Self-Assessment Questions (ASAQ)

ASAQ 15-1
Cause Sub-Saharan Africa Developed
% Rank % Rank
Bilateral tubal occlusion 41.9 1 10.6 5

Ovulatory disorders 17.9 2 24.8 2
Pelvic adhesions 11.1 4 12.4 3
Acquired tubal abnormality 10.3 5 11.2 4
Hyperprolactenimia 4.3 6 6.7 6
Endometriosis 0.9 7 5.7 7
No demonstrable cause 13.7 3 28.6 1
Congratulations! If you got it all. If not, you may want to look again at
Figures 15-1 and Figures 15-2 to check on the data.
ASAQ 15-2
Cause Laparoscopy with Hysteroscopy MRI
hydratubation
Obstructed fallopian tubes 3

Endometriosis 3 3
Pelvic adhesions 3
Ovulatory disorders 3
Uterine septum 3 3
Laparascopy with hydratubation is useful for conditions found in the pelvic

cavity but outside of the uterine cavity. For conditions within the uterus,
then hysteroscopy and MRI are applicable.
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Module 15 453
ASAQ 15-3
The procedures in the following techniques are as follows:
1. GIFT — the ova are retrieved from the ovary using laparoscopy and
these ova (up to 3 oocytes) are transferred in the fallopian tube during
the same operation. The loaded transfer catheter is inserted into the
fimbrial orifice, about 2-4 cm and the content are unloaded into the
fallopian tube.
2. Zygote Intra-Fallopian Transfer (ZIFT) — the mature oocytes are ob-

tained by laparoscopy and in-vitro insemination of the oocytes is done.
When the ova are fertilzed, the cleaving embryos are transferred to
the fallopian tube, as in the GIFT.
3. Pro-Nuclear Stage Transfer (PROST) - the procedure is very much like

the ZIFT method except that the embryos are transferred during the
pro-nuclear stage to reduce the exposure of the embryo to laboratory
conditions.
Did you get all these procedures? I’m happy if you did because this ques-
tion required a lot of recalling!
If you did not get the correct answers, don’t feel too bad because this
question is quite technical. Reread the description of the process.
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Module 16
Issues on Fertility
and Infertility
Teresita I. Barcelo, R.N., Ph.D.
N owadays, diseases like cancer, diabetes or

heart disease can be detected as early as the
embryonic stage. Even couples who, for one rea-
Objectives
son or another cannot bear children of their own,
At the end of this module,
can have a child using their own gametes but
you should be able to:
whose fetus will be carried in pregnancy by an-
other woman (surrogate motherhood). You may
1. Discuss the current issues
have also heard by now that Down’s syndrome
related to reproductive
can be diagnosed while still inside the uterus.
technologies in fertility
Because of this availability of prenatal diagnosis
and infertility diagnosis
of Down’s syndrome, many couples are opting
and management in
to have abortion particularly done in countries
terms of its ethical, legal,
where abortion is legal.
and technological
dimensions; and
With all these overwhelming advances in repro-
2. Derive implications that
ductive technology, professional health workers
can serve as guidelines
like nurses cannot help but ask questions like:
in determining bio-ethical
norms/standards in the
1. Can the parents decide on the life of the un-
delivery of nursing care.
born child, on the question of the quality of
life of the child in the future?
2. Can the mother decide to abort her unborn child for the simple reason
that the baby is an obstacle to her career?
3. Can an infertile couple hire the services of another woman to bear a

child for them?
4. Should a health worker use a technology which is yet highly experi-

mental and which has not yet been adequately tested for its safety
and efficacy?
The RA 9173 Philippine Nursing Act of 2002 and the BON Res. 220 s.
2004 Code of Ethics for Filipino Nurses state that all nurses must do ac-
tions intended to protect life and promote health in all stages of develop-
ment. As health care providers, nurses must seek out the truth in these
various ethical issues being discussed, be discerning when evaluating the
veracity of voluminous information regarding the subject of reproductive
health, and be ready to be an advocate for both mother and child.
Before reading the text, it would be to your advantage if you have already
completed reading the modules on detecting ovulation and advances in
controlling fertility.
So far, three of the more commonly discussed issues are: the right to life
even of the unborn, the dignity of the human person, and the right to
informed consent.
Sometimes the nurse is caught in a dilemma about what to do when con-

flicts arise between the right of the unborn child to life and the right of the
mother to decide whether she likes to have a pregnancy or not. For
example, as a family planning motivator, you may find it difficult to de-
cide in the first place whether to encourage the mother to observe contra-
ception or not if you yourself do not believe in the basic philosophy of
limiting the number of one’s children.
Moreover, you may be in a dilemma whether to give full information to

the mother about contraceptive devices that are still experimental. Or,
you may be hesitant to give all the undesirable side effects associated with
certain contraceptive method such as early abortion or abortifacient, ef-
fect on the baby if the hormone is taken even when pregnancy is likely to
be present, high risk for infection, and the danger of sterility after pro-
longed use.
The second issue on the “dignity of man” can well be seen in such ques-
tions as “When does life begin?” or “Is abortion and the use of abor-
tifacients immoral?”
UP Open University
Module 16 457
As these issues continue to hug the headlines, the fundamental concept of

respect for life and the dignity of the human being, born and unborn,
seem to become muddled by the concern for economic prosperity what-
ever the cost. There is also a growing view in many countries that pain
and suffering should be eliminated. Thus, euthanasia is advocated to end
the misery of people, young or old, especially if they are congenitally de-
fective or terminally ill.
Respect for the dignity of humans is also reflected in how one views the
value of women vis-à-vis men. With the current high technology able to
determine the sex of the child, do you think there will be an intensifica-
tion of the prejudice against women? Are you aware that there are cul-
tures favoring the birth of a son more than that of a daughter? There are
also countries with government policies limiting couples to have only one
child so that families have to resort to abortion or infanticide if the fetus is
a female. Will these technologies now available perpetuate this sexist dis-
crimination against women?
Issues in Fertility Control

Advances in fertility control has led to reduced birth rate in many devel-
oped countries. The world population is getting to be an aging one. Soon
there will be more old people than young ones. With the zero or near-zero
growth rate in many affluent countries, eventually these countries will
have an inverted pyramid population. Figure 16-1 illustrates this concept.
Notice that the base of the population pyramid which is composed of the
young population is small and the tip of the pyramid which is composed
of the older population is broad. This type of population structure will
affect the development of these countries because the young, working
population group is fewer than the older population group whom they
are supposed to support.
There are many feminists who believe that women have the absolute right
to decide when they like to become pregnant so that an “unwanted, un-
timely” pregnancy must be terminated because their right prevails over
the right to life of their child. While there are attempts to legalize abortion
in our country today, these efforts will not prosper because our 1987 Con-
stitution provides in Article II, Section 12 that the State must guarantee
the right to life of the unborn child from conception equal to that of the
mother.
UP Open University
Age in Years
70 and over
65-69
60-64
55-59
50-54
45-49
40-44
35-39
30-34
25-29
20-24
15-19
10-14
5-9
0-4
Economically
Legend:
active
Figure 16-1. Inverted pyramid population
Have you noticed that in the Philippines today, there is a strong move by
the government and some private family planning orgaizations to further
reduce the growth of our population? Some of our population demogra-
phers and political leaders hold a simplistic view that the development of
our country will be faster if there is a smaller population without the need
of developing the other important aspects like adequate basic services,
enough employment opportunities, peace and order, and moral upliftment
of the people as well as of the leaders of the country. Thus, the artificial
fertility control and sterilization programs of the country are being pushed
aggressively and sometimes even without the informed consent of the
women themselves and/or their husbands.
UP Open University
Module 16 459
An issue particularly related to fertility control is informed consent. There

are some birth control drugs which are in fact banned in some developed
countries which are being dumped in developing countries like the Phil-
ippines. There are also artificial birth control drugs and devices that are
still experimental in nature and whose efficacy and safety have not yet
been established, but are being tried out on Filipinas who are not fully
informed of the situation.
Have you ever scrutinized the literature that go with many of the hor-
monal contraceptives or intrauterine device? Or have you heard a health
worker motivate a woman to use contraception? Was there any explicit
statement given that the contraceptive method is abortifacient or cause
early stage abortion? Were these women informed that some of the hor-
monal contraceptives can fail and the chance of pregnancy occurring.
The literature is very carefully worded to avoid the word abortion. Don’t
you think a simple, explicit description of the abortifacient effect ought to
be included in the same way that our government requires the warning
concerning the less morally sensitive issue of the tobacco?
Providers and promoters of abortifacient drugs in contraceptives should

honestly label their products. If they have chosen to reject the right to life,
the least they can do is to allow others the ability to exercise their freedom
of conscience. They can give all the women of the world a true freedom of
choice only by stating simply and honestly what their product does.
Many health workers would rather promote contraception in order to

prevent abortion. But do you know that according to the World Health
Organization (1989), “there is a positive relationship between contracep-
tion and abortion”. This positive relationship is, in general most marked
at the point when society begins to accept the need to limit reproduction.
This is probably due to two possible reasons. First, is the fact that indi-
viduals often feel pressured to limit their family size before effective and
acceptable contraceptives are available to them and second, they feel pres-
sured to use contraceptives even if they have not yet learned to use them
effectively. Abortion is sometimes used as a back-up in case of contracep-
tive “failure”. No method of contraception is absolutely reliable even when
used responsibly. So, failures of contraception are inevitable.
According to WHO (1989), the experiences of the Republic of Korea and

China (Province of Taiwan) illustrate well the positive relationship
between abortion and contraception. It is sometimes argued that liberal-
izing abortion laws will lead to less widespread or irresponsible use of
contraception but there appears to be no evidence to support this view.
Moreover, according to WHO, abortion seems to increase the demand for
contraception. Research in many countries shows that women are most
receptive to contraception counseling immediately following abortion.
UP Open University
Contraception cannot altogether eliminate the need for abortion. Accord-

ing to Moore-Caver (cited by WHO, 1989), “abortion and contraception
are the two faces of the same coin.” Thus, this danger in contraception is
the creation in the mind of the users, including the providers, of the con-
traceptive mentality which make them open and receptive to the idea of
induced abortion. Since the pregnancy is a failure of contraception and
the couple actually did not want the pregnancy that is why they use con-
traception, resorting to induced abortion will be the logical consequence.
Issues in assisted reproductive technology

The use of assisted reproductive technology has both ethical and legal
issues. The common issues that arise are:
1. paternity rights in “other-than-the-husband” artificial insemination

2. parental rights in surrogate motherhood
3. legal rights of frozen ova
4. creation of human embryo for research and cloning of human beings
It has always been held that a good end or the attainment of useful goals
cannot be the sole criterion for human moral conduct in any area whatso-
ever, including that of medicine. Genetic engineering is doubtless a sci-
ence that offers advantages to humanity and to the reproduction of the
species. However, in order for it to be “human”, i.e., corresponding to the
values of the dignity of the person and of his rights, it must always serve
him by improving the quality of his life through the elimination of heredi-
tary defects or other possible disorders.
When genetic engineering places itself above or beyond ethical and legal
norms based on the primacy and dignity of the person; when it violates
the rights of even one human being, it becomes a perverse tool that can be
neither accepted nor permitted.
The use of technology in reproduction and genetic screening also brings

unique questions of discrimination, exploitation of women, and the pros-
pect of a commercial eugenics and biological warfare. Should biotechnol-
ogy be allowed to play God? Prolonged and expanded use of these engi-
neering feats could mean the end of the natural world as you currently
know it.
Even when nurses believe that certain reproductive technologies being

done in their institution violate the right to life of the unborn child or the
woman’s right to informed consent, they choose to keep silent because of
the fear that their superior or employer may terminate their employment
if they speak out.
UP Open University
Module 16 461
Some nurses may shy away from discussions of the assisted reproductive
technology issues for fear that they may not be able to articulate well their
position and be ridiculed by their colleagues or co-workers if they hold
contrary views. As a patient advocate, the nurse should protect the rights
of the clients both born and unborn. But it is not easy for the nurse to be
an advocate of the unborn child who is seen by many people as the mother’s
extension as long as the child is still in the mother’s womb.
In all these issues on reproduction, we must always keep in mind that in

the Philippines, abortion is illegal and unconstitutional. In case of moral
dilemma, remember to follow the principle of double effect which states
that an action is moral only if the following four conditions are met:
1. the act is good or at least neutral;

2. the good effect is intended;
3. the good effect comes before the bad effect.
4. the good effect outweighs or at least equals the bad effect.
Activity 16-1
The reading materials provided have been selected for the varied
issues they present. This is not to say that these are the only issues
related to reproductive health.
Read the articles below, copies of which are in the supplementary

readings. After reading each article, answer the guide questions
provided for each article. In your discussion of the answers, you
may cite other literature which you have read to support your
viewpoint. However, do not forget to document them properly.
Article 1:
Valenzona, Rosalina. “What Everyone Should Know About the
Philippine Population Program.” Vital Signs. September-October
1993, pp. 32-38.
Questions:
1. Some people say that Philippines is over-populated while oth-
ers say that it is not. What is your opinion? Explain and sup-
port your answer.
2. What direction should be taken by our policy makers regard-

ing our population growth? Why?
UP Open University
Activity 16-1 continued
Article 2:
Sumera, Tubani. “More than Sexist.” Healthstring. Spring, 1991,
pp. 10-13.
Questions:
1. How will these advances in reproductive technologies affect
women? Explain and support your answer.
2. List the issues being raised by the author. What is your own
stand on these issues?
Article 3:
San Luis, Teofilo. “Moral and Ethical Issues in Assisted Reproduc-
tive technologies.” Vital Signs, n.d., pp. 57-59.
Questions:
1. List the moral and ethical issues cited by the author regarding
reproductive technologies.
2. What is your own assessment of the ethico-moral issues dis-

cussed in the article? Explain and support your answer.
Article 4:
Freda, Margaret Comeford. “Childbearing, Reproductive Control,
Aging Women, and Health Care: The Projected Ethical Debates.”
JOGNN, vol. 23, no. 2, February 1994, pp. 144-152.
Question:
Be ready to discuss your answers with your classmates during the
tutorial session or online discussion. Focus your discussion on
whether a similar social trend is likely to occur in developing coun-
tries such as the Philippines. In addition, make your own projec-
tions on the possible ethical concerns related to reproductive health
of aging women, aging in women and childbearing in our coun-
try.
UP Open University
Module 16 463
Comments on Activity 16-1

Your reactions/answers to the guide questions must be based on
the content of the articles. However, your justifications maybe
drawn from your readings of the modules and other sources. Be
prepared to share with your colleagues your reactions/answers
during your study session.
Article 1:
Your view about the status of the Philippine population must be
based on our population profile and our population density. You
may want to distinguish the population status in the major urban
areas which are overpopulated and the status in the rural area
which is still sparsely populated.
The direction of our government policy should be towards address-

ing the root cause and not just on the peripherals or symptoms.
Article 2:
The author describes a number of advances in technology and the
concomitant issues that affect women. There are in-vitro fertiliza-
tion which makes possible surrogate motherhood; sex determina-
tion in utero which makes possible abortion on demand for female
fetuses (femicide); tests to detect disabilities/inherited diseases in
the fetus while in utero which makes possible a “designer baby”
and abortion on demand for defective babies. The basis of ethical
issues here are respect for persons regardless of sex and respect for
life.
Article 3:
The author raised three issues: (1) the place of human procreation
in marriage; (2) the dignity of the couple and truth in marriage;
and (3) surrogate motherhood. Your discussion should revolve
around these three issues.
Article 4:
Your reaction paper should focus around three ethical issues: (1)
shifting demographics of age and race which is happening in the
U.S.; (2) the fundamental change in the health care system to a
community-based, preventive model; and (3) the equal voice of
women in government. Do you also see these issues occurring in
our society in the near future.
UP Open University
Summary
The care of mothers and children is one area of nursing that is quite open
to ethico-legal issues and concerns because many times conflicts arise bet-
ween the rights of the mother with that of the child. The three common
ethical issues discussed are the right to life, respect for the dignity of men
and women, and the right to informed consent.
In the ethical issue about the right to life, the common dilemma is in deter-
mining whose rights should prevail, that of the mother or that of the child,
as in the case of abortion-on-demand of the mother or contraceptive de-
vices that are abortifacients.
The second issue refers to respect for the dignity of men and women, able-
bodied or less-abled. This respect for both sexes presupposes that each
has a significant contribution to make to humanity and that not one of
them is less desirable. This issue is seen in such cases as selective infanti-
cide for female fetuses, induced abortion for congenitally defective or dis-
eased fetus or selection of the “best” embryo for the ZIFT or GIFT.
The third issue is related to informed consent. Couples need to under-

stand the advantages and disadvantages including risks of the clients of
the various technologies available before they are subjected to them. Con-
traceptive devices and reproductive technologies that are still experimen-
tal and not yet tested for their efficacy and safety need to be used with
caution and only after a thorough explanation has been given to the couple.
UP Open University
Module 17
Psychosocial Problems
of Women
Ma. Estela M. Layug, R.N., M.A.N.
W hile it is true that there has been a univer-

sal improvement in women’s status in the
past decade, still and all, women are paid less
Objectives
than men for the same work, decrease in women’s
literacy rate has slowed down, and women ac- At the end of this module,
count for a larger portion of the world’s poor. you should be able to:
In fact, from the beginning, girls are discriminated 1. Analyze the interplay of
against. Even in this day and age, millions of girls of factors related to
being conceived across Asia will not live long psychosocial problems
enough to “see the light of day.” In some rural of women; and
communities in China, baby girls are drowned 2. Derive implications on
or abandoned to starve, or given inadequate post- the role of the nurse in
natal care so that they die of disease. Female new- alleviating the psycho-
borns are left outside some 900 orphanages across social problems.
the country. Why? Because in China, there is a
“one child” policy and boys are preferred because boys can work and
inherit the family land, they are the ones who will carry on the family
name and they can look after parents when they are old.
In some places in India, baby girls’ backs are broken at birth, or they are
buried alive in the sand, or even poisoned by tobacco leaves stuffed down
their throats. One Bombay clinic reported performing 8,000 abortions,
7,999 of which were girls. Why? Because in India, even the poorest of
families have to pay dowries for daughters, and for them, the way to
avoid this is simply to kill baby girls. Besides, doctors and government
agencies feel there is nothing wrong with aborting females because it helps
check population growth.
Surveys in South Korea show they do not have any special prejudice
against girls. And Koreans are financially secure enough not to need sons
to look after them when they are old. But, they want small families. Also,
which I think is more important, there is a rule about sons carrying on the
family name, in keeping with Confucius’ philosophy. “There are three
ways of being disloyal to your ancestors. Not carrying on the family line is
the worst.”
Even in the rich, literate country of Taiwan, where abortion is supposedly

strictly limited by law, bringing up children and educating them is very
expensive. So, to restrict the number of children, sex-detection techniques
like ultrasound and amniocentesis are done to identify females and abort
them. In many private elementary schools in Taiwan, there are five classes
for boys and only two for girls.
All the above discussion point to one glaring truth: when it comes to psy-
chosocial problems of reproductive health, only one end of the gender
pendulum is at a disadvantage—women’s. These psychosocial problems
do not occur in isolation. There is rape in marriage where the wife is also
battered. There is also rape in prostitution. Unwanted pregnancy may
also be a case of rape, prostitution or child abuse. In the same token, it
would be difficult, if not possible, to point an accusing finger on any one
isolated variable. Is it proven? Or improving economy? Societal attitudes?
Or even politics? In short, there is a whole lot of entangled psychosocial
mess in problems involving women.
This module is all about the interfacing of these multiple psychosocial

factors that contribute individually and collectively to gender violence.
Yes, this module might as well be re-titled. Violence Against Women. For
aren’t abortion, spouse abuse, sexual harassment and rape “violence” in
one form or the other?
Violence Against Women

There is no denying the fact that in comparison with their Asian sisters,
Filipino women are socially better situated. For one, Filipino women do
not suffer from the more glaring practices of gender inequality such as the
dowry system, genital mutilation, vaginal sewing, wife burning, or fe-
male infanticide. In our country, women walk, literally and figuratively,
UP Open University
Module 17 467
alongside men. Government itself is slowly taking pains to ensure as much

gender equality as possible. In fact, the Philippine Development Plan, is
an addition to the Philippine Constitution, and the revised Family Code,
which all explicitly reflect support for women.
Despite all efforts, women in the Philippines remain victims of a host of

interrelated and interpenetrating factors which produce and reinforce
inequality. They have to grapple with such sociopolitical spheres of dis-
crimination as economic marginalization, political subordination, gender
stereotyping, multiple burdens, violence against women, and obstacles to
personhood development (Philippine Plan for Gender-Responsive Devel-
opment Plan, 1995).
Violence Against Women (VAW) is a serious and urgent human rights

concern for many Filipino women. VAW is not purely a woman’s prob-
lem. Gender violence can serve as a “brake on socioeconomic develop-
ment, a serious threat to national growth and efforts to attain peace”
(Philippine Plan for Gender-Responsive Development, 1995).
Unfortunately, only women are potential victims in domestic violence,

the perpetrators are the males, either relatives, intimate partners, acquain-
tances or total strangers. In September, 1992, the United Nations Com-
mission on the Status of Women drafted a declaration against VAW, de-
fining it as:
“...any act of gender-based violence that results, or is likely to re-

sult, in physical, sexual or psychological harm or suffering to women
including threats of such acts, coercion, or abitrary deprivation of
liberty, whether occurring in public or private life.”
To be able to fully understand the gravity of the problem, nurses should

understand the nature, causes, and consequences of VAW from the per-
spective and experiences of the women themselves. All women are vul-
nerable to violence. It happens to women even in familiar and intimate
settings, e.g., in the home, neighborhood, workplace, school, and in pub-
lic places. Family structures and arrangements can reinforce violent be-
havior in men. Early in life women are made to believe and feel that males
are powerful and, therefore, dominant. And that violence is an accept-
able means of ensuring male dominance as well as resolving conflicts. The
father is the head of the house and as breadwinner is allowed full free-
dom to do whatever he wants, including beating up his wife and molest-
ing his own daughter.
On the other hand, girls are encouraged to be sweet, submissive, and

demure. This conduct is carried well into adulthood so that they are led
into believing that they can do nothing when confronted by male assail-
UP Open University
ants, whether they be husbands, fathers, or strangers. The wife is expected

to serve and please the husband, especially if she is economically depen-
dent on him. The children, particularly the daughters, are the most pow-
erless and the most vulnerable to abuse by the father and the other male
members of the family.
Certain conditions and attitudes of society likewise contribute to the cycle

of violence. The community considers the family of prime importance and
dictates that it remains intact at all cost, even at the expense of a woman’s
dignity. In fact, some communities ostracize women who resist the tradi-
tional mold of mother, wife and homemaker.
Incidentally, there is no truth to the rumor that perpetrators are usually

drunk, mentally incapacitated or under the influence of drugs or the devil’s
spell. The fact is, they are often normal, respectable and even considered
“productive” members of society. Frequently, they are aware of what they
are doing and their acts of violence are done repeatedly and consistently
done over time. It is sad that, society silently condones this behavior and
thus conditions males and females to accept violence as a fact of life.
Actually it is our basic attitude and unexamined perceptions that camou-

flage the fact that VAW is based on an ethnic domination and power, of
gender expectations and social milieu that has a high tolerance for vio-
lence. It is a symptom of the following complex and interacting factors
(PPGRD, 1995):
1. A culture of violence
2. Gender prescription that vest social power on men
3. Resulting psychological make-up of both victims and perpetrators
4. Values and attitudes that are derived from and contribute to gender
inequality
And because of all the above, the following forms of violence are being
experienced by Filipino women:
1. Marital rape. Unfortunately, it is acknowledged because of the erro-

neous belief that marriage gives the man full and unequivocal access
to the women. You must remember that it is every woman’s right to
refuse sexual relations even with her husband.
2. Incest. This is the commission of sexually inappropriate act or acts

with sexual overtones with a child or adolescent, by an older person
who wields authority through emotional bonding with that child.
UP Open University
Module 17 469
3. Reproductive rights violence. It includes forced pregnancy, forced

sterilization, forced abortion, or denial of complete and accurate in-
formation to safe birth control methods and reproductive technolo-
gies.
4. Sex discrimination. Otherwise known as sexism, it occurs when

women, because of their gender, are accorded low status and are not
allowed equal access to education, employment, social and other op-
portunities for advancement.
5. Lesbophobia/hemophobia. Affected are lesbians who, because of their

sexual orientation, are subjected to discrimination, ridicule, harass-
ment, or verbal and physical abuse.
6. Medical abuse. It refers to unwanted or unnecessary surgical inter-

ventions, e.g., internal exams, cesarean sections or hysterectomies.
7. Culture-bound practices harmful to women. Some examples are ar-

ranged marriages and even the undue importance given to virginity.
8. Ritual abuse within religious cults. Women are used as sacrifices or

offerings in ceremonies where they are sexually violated, abused or
raped.
9. Sexual slavery, prostitution and international trafficking of women.

Remember the now-famous “comfort women” who were abducted,
sexually abused and kept as chattels by Japanese soldiers during World
War II? This is sexual slavery. Prostitution is defined as giving sexual
favors in exchange for cash or other material remuneration. The ex-
tent of trafficking of women workers has worsened. These women
are also subjected to various forms of inhuman treatment ranging
from battery to rape, to murder, such as in the cases of Flor
Contemplacion and Sarah Balabagan.
10. Pornography and abuse of women in media. There seems to be no

end to the way show business and media debase women. Display of
all those pin-ups in magazines and the tabloids and the huge bill-
boards around is really revolting.
11. Custodial abuse. The women here may be a resident, patient or ward
of a rehabilitation center, mental hospital, medical clinic, foster home
or a detainee in jail. The assailant is someone who has authority and/
or supervision over her.
UP Open University
Activity 17-1
Collect 3 to 5 newspapers a day for one week. Make a survey of
news items about different forms of violence. Be prepared to make
an oral report during your study session or online discussion in
terms of the following:
1. Type of violence as classified above

2. Age of victim and attacker(s)
3. Place or location of incident
4. The precipitating or predisposing factors, if known
5. Circumstances, i.e., the event itself
6. Outcome(s), e.g., Was the attacker apprehended or has re-
mained at large? Did the victim report the incident immedi-
ately? How did the public come to know about it? Through the
police blotter? Did the victim air her complaint through a ra-
dio station, or to an NGO?
For the purpose of this particular course, and for advocacy reasons as
well, this module will attempt to discuss only three of the most prevalent
forms of violence in our country today: domestic violence, rape, and sexual
harassment.
Domestic Violence
A popular actor was interviewed while coming out of the hospital to-
gether with his live-in partner. The latter was treated for a gunshot wound
in the hand after a fight. The woman in this case refused to comment or
file charges against the father of her two children. The actor explained,
“Away pampamilya lang ito.” (“Just a family problem.”) This statement is
the very reason why wife beating has remained a problem. It has been so
privatized that it is beyond the reach of the law and socially considered to
be natural between spouses.
In police blotters, domestic violence as a crime category used to be non-

existent. The experience in crisis centers in our country is that battered
women have been subjected to prolonged or repeated violence. Would
you believe that it takes 30-50 years for some women to be able to muster
enough courage to come out in the open and tell her story? There have
been reported instances when women have been finally murdered by their
spouses after many years of escalating violence. The puzzling question is,
UP Open University
Module 17 471
“Why do these women stay?” They enjoy it? They need it? They deserve
it? Or even instigate it? The real reasons are myriad, complex, and vary
from one women to the other. If you expect that any reasonable person
would avoid her attacker even after the incident, you are wrong. If you
think this way, Gelles (Benton, 1986), says you overlook the “complex
subjective meaning of intrafamilial violence, the nature of commitment
and entrapment of the family as a social group and the external con-
straint which limits a woman’s ability to seek outside help.” Take note of
the fact that although the following factors have been identified, they
actually interact in complex ways.
1. Economics. The cornerstone of victimization is in economics. Many

battered women are unskilled or unemployed. But there are also bat-
tered women from the middle and upper classes. In this latter situa-
tion, they have little or no access to funds. They fear poverty if they
leave. The acquisition of resources is therefore a crucial need for these
women so that they can extricate themselves from the situation. “The
fewer resources a wife has in marriage, the fewer alternatives she has
to her marriage” (Gelles in Benton, 1986). Employment for these
women will not only alleviate financial dependence but will also
broaden their entire outlook.
2. Cultural and religious factors. Male dominance is a respected tenet

in nearly all cultures. Men are socialized to feel uncomfortable when
not “in control” and women are socialized to accept this. The author-
ity that the husband wields entraps and keeps the women in constant
fear, causing her to “suffer in silence.” Even the community itself turns
a blind eye to family violence. It virtually excuses a husband’s violent
behavior. According to Piglas Diwa (1994), one battered wife said,
“Ang payo ng aking magulang ay pagpasensiyahan ko siya dahil asawa ko
siya.” (“My parents say I should give way because he’s my husband.”)
Many religions consider the maintenance of the family unit to be of
primary consideration. Remember the oft-repeated phrase, “What God
has put together, let no man put asunder?” or “Till death do us part?”
Incidentally, it is common belief that battering husbands are usually

under the influence of alcohol or drugs. This has been found to be
untrue. Alcohol or drugs may be a facilitator, but not a cause. They
are often normal, respectable individuals who are “productive” mem-
bers of society. They are aware of what they are doing. Eight out of
ten are employed and they include government officials, doctors, busi-
nessmen, military men, teachers, security guards, bus conductors, ven-
dors, factory workers, scavengers.
Study have shown that there is diversity not only in educational level
but in age range as well.
UP Open University
3. Legal system. Even the nature of our legal system may explain why a
woman stays in a violent relationship. The process can really be so
tedious and exasperating. Police who respond to a complaint of bat-
tering may feel the problem is not their business. Do you think judges
will be more interested? Or better yet, do you think the woman herself
would be willing to go through the time-consuming and expensive
process? Not only the legal system but also the attitudes of health care
professionals can be potentially damaging. Shipley (in Henderson,
1994) found that many health care workers are insensitive to the prob-
lem of violence. While they treat the injuries, they ignore the cause.
4. Psychosocial factors. The psychosocial factors are more important

than anything else. One of the most striking characteristics of battered
women is their extreme degree of isolation. Many of them have no
close friends or relatives with whom they can share their concerns.
This social isolation is crucial because it adds to their poor self-esteem
and engenders feelings of helplessness and powerlessness. Perhaps
too, the embarassment and guilt may cause them to withdraw from
social contact. Battered women often blame themselves for their pre-
dicament. Many of them were abused as children. As the saying goes,
violence begets violence. The intergenerational transmission of vio-
lence in fact is what actually perpetuates family violence.
A woman’s fear of emotional damage to her children may be another

reason for staying. The saying, “for the sake of the children” is common.
Or, if the woman leaves home without her children, she may face legal
battles to get them back.
Frequently, the question becomes “Which is worse, living with him or

leaving him?” Several studies on battered women (Schhchter in Benton,
1994) found that some women prefer to be married to a batterer than not
to be married at all. It is either due to a fear of loneliness or the hope that
he will change for the better. Whatever the reason, for many of them the
emotional risks of leaving seem to outweigh the benefits.
One psychosocial explanation is the concept of “traumatic bonding.”

Women with low power have low self-esteem and therefore feel inca-
pable of fending for themselves. They come to feel dependent upon the
more powerful partner. Consequently, the battering person develops a
sense of power dependent on his partner’s lack of power. A psychosocial
symbiosis is created, locking both partners into the relationship (Dutton
and Painter in Benton, 1994). The dominance-submission dichotomy, the
batterer’s use of isolation, fear arousal, and guilt induction, all of these
only serve to perpetuate and maintain violence. In a battering relation-
ship, what alternatives can a woman weigh when her options are actu-
ally few?
UP Open University
Module 17 473
Violence, being a socially-learned behavior, can be unlearned. Organiz-

ing the whole community is the key towards sociocultural change. The
act of repeatedly exposing wife beating as a crime against women through
the use of mass media is significant. Crisis centers have been established
for the protection of abused Filipino women. With a more solid support
network and legal and medical advocacy programs, there is hope for de-
creased incidence of domestic violence, if not its total eradication.
Activity 17-2
Henderson and Ericksen (1994) commented that nurses are insen-
sitive to the problem of violence. They are reluctant, if not afraid,
to intervene in problems of domestic violence because they believe
that “battery is a social or legal problem, not a health care prob-
lem.” They also fear that they might do more harm than good.
In not more than five paragraphs, give your personal reactions to

Henderson and Ericksen’s observations.
Explain whether you agree that nurses are not competent enough
to care for victims of domestic violence. What is the role of nurses
in alleviating the problem of domestic violence? Explain your an-
swers.
Write down your answers and be ready to discuss this with your
classmates and tutor during your study session/online discussion.
Rape
Our country has been rocked by media accounts of gruesome cases of
rape and even rape-slay. There was the filed saga of Myrna Diones who
miraculously survived rape by policemen who have since been convicted.
The Calauan rape-slay of a UP student and her friend by the town mayor
who has also been convicted and is now in the National Penitentiary. The
rape-slay of a mother and her daughters in their Parañaque house sup-
posedly by sons of prominent families, the Batangas and the Marikina
series of rapes which claimed 17 young women within a span of only
eight months are incidents that have raised public outrage. The alleged
rape case of a Filipina done by four US servicemen is both traumatic to
the victim and the Filipinos in general because it also raises a sensitive
political issue of our own sovereignty.
UP Open University
According to statistics from the Philippine National Police (PNP), babies

as young as eight months old and women as old as 70 years have been
raped. Their unofficial estimates say that all over the country today, at
least one rape occurs every six hours, or four rapes a day. The most unfor-
tunate fact is that only two out of 10 incidents are reported. And while
there is a decrease in such index, crimes as murder and robbery, there is a
25% increase in the incidence of rape nationwide!
Art. 335 of the Revised Penal Code states:
“Rape is committed by having carnal knowledge of a woman un-

der the following circumstances:
1. by using force and intimidation

2. when the woman is deprived of reason or is unconscious
3. when the woman is under 12 years of age.
According to the Women’s Legal Bureau, the definition implies two things.
First, the offender and the offended party cannot be of the same sex. Car-
nal knowledge is the legal term for sexual intercourse and it is defined as
penile and vaginal contact. Therefore, the offender must necessarily be
male and the offended party female. Second, oral and anal sex, insertion
of foreign objects or other bodily parts into the vaginal, anal or oral orifice
and forced sexual intercourse with an animal do not constitute rape. These
are classified as acts of lasciviousness. They are considered less serious
crimes and therefore have lesser penalties.
If the victim claims that she has been forced into sex, she must present
proof of her resistance. Verbal resistance alone will not suffice. She should
prove that she really put up a good fight, as evidenced by torn clothing
and body injuries. This requirement, though, fails to consider the situa-
tion of the woman at the time of the crime. But, resistance may not al-
ways be the best course of action. What if she gets savagely beaten or
killed by resisting? Or, she may have been totally shocked with fear as to
be unable to command her body to fight back. Our legal system sees to
have conjured a picture of what a rape victim should be—battered, bleed-
ing, and hysterical. If law enforcers and medical officers fail to see the
stereotypical victim, the tendency is to doubt the woman.
Indeed, it is frequently said that during the prosecution of rape cases, the
complaint is as much on trial as the accused. It is much like being “raped
for the second time.” The complainant’s past sexual history is paraded in
court and she is even made to give a “blow by blow” account of the inci-
dent! Rape assaults not only a woman’s body, but also her senses, emo-
tions, dignity and integrity. The act destroys her very humanity.
UP Open University
Module 17 475
Sadder still is the fact that people say that the victim could have warded
off the attacker “had she fought hard enough.” Isn’t it true that com-
ments like “She had it coming to her” even blame the victim for wearing
sexy clothes or being out at night? That the Women’s Crisis Center has
refuted this by saying that rape is not commonly done by “strangers jump-
ing out of the bushes” on unsuspecting women. Of 79 rape cases, only 7-
9% of the perpetrators were complete strangers. Seventy-two (91%) were
known to the victims. Incest comprised 23 (32%) of the cases of rape by
known assailants. Worse, though, is the false notion that women falsely
accuse men of rape.
Do you know that there are several types of rape?
1. Date or Acquaintance Rape. The assailant is either the victim’s suitor,

boyfriend, neighbor, co-worker or member of her peer group. And
they say this is a problematic area. People tend to accuse the victim of
cooperation and even consent in this situation.
2. Stranger Rape. The attacker may not be known to the victim, but in
many instances, may have prior knowledge of his victim.
3. Gang Rape. The assailants come in numbers and may either be com-
plete strangers or casual acquaintances of the victim.
4. Military Rape. May be part of political torture, or used as a tool to

extract information, humiliate, degrade, and breakdown the victim’s
will. The victims thus far are those who have been accused of subver-
sion or are threats to national security. They are activists, peasant
women, workers, students and mass leaders.
5. Mass Rape. Victims are usually the women in war-torn communities

who are sexually assaulted by para-military or military groups or armed
men.
6. Rape-Slay. The victim is not only raped, but is also killed.
We are aware of the fact that rape is a sexual crime. But it is also a mani-
festation of the prevalent patriarchal attitudes of society toward men—as
sex objects, as property to be possessed by men and as having been cre-
ated to serve men.
UP Open University
Sexual Harrasment
I have always thought that sexual harassment is a new name for a prob-
lem which is certainly not new. Rather, it is the expressed concern which
is relatively recent. Some observers have said that it is “much ado about
nothing” and that it is an inevitable consequence of men and women
working together. In short, for some people, it is harmless fun. But there is
a big difference between social interaction at work and sexual harass-
ment. The former involves social relationship mutually entered into, while
the latter is an imposition of unwelcome attention or action on one per-
son, often by one in a superior position.
Sexual harassment was first identified in the United States 10 years ago.
In our country, it was only 1995 when Republic Act 7877, otherwise
known as the Anti-Sexual Harassment Act, was passed.
In sexual harassment, women are often the victims, and men the preda-
tors. As one author said, “harassment of men by women is so rare that it
is difficult to unearth examples” (Pattinson, 1991). Both sexes agree that
what is harassment to one may not be harassment to another. The only
real test is how the victim reacts to the unwelcome attentions of another
and what she can and should do about it.
We can take note of the fact that the sexual harasser does not necessarily
have to seek sex, although it it said to be a prime motivation in most cases.
The chief motivation has all to do with power: the power to belittle, de-
grade and humiliate, block promotion prospects, and even to dismiss and
demote.
According to guidelines set by the U.S. Trade Union Congress which have
become the code of practice in workplaces everywhere, sexual harass-
ment may take any of the following forms:
1. ridicule, embarrassing remarks, or jokes, and unwelcome comments

2. suggestive remarks or other verbal abuse
3. leering at a person’s body
4. compromising invitations
5. demands for sexual favors
6. physical assaults
Unwelcome comments can include remarks about dress or appearance,

deliberate abuse, the offensive use of pin-ups, pornographic pictures, re-
peated and/or unwanted physical contact.
UP Open University
Module 17 477
Sexual harassment is one other evidence of gender inequality, of “men’s

power over women.” Women continue to be confined to the low-paid,
semi-skilled and low-status jobs while men predominate in the higher-
paid supervisory and skilled jobs. The prevalence of society’s attitude to-
wards women as “lower status, secondary workers” fosters situation where
a male worker will use his actual or potential power over a female worker
to “keep in her place.” Thus, when sexual harassment is talked about, it is
usually in the context of the office where there is a clear-cut division of
status between female secretarial staff and male management. It can also
be in male-dominated industries, or a product of male resentment about a
woman doing a particular job. The harasser may be in the same status job
as the woman involved. If the harasser is in a lower status job, the un-
wanted attention is usually used as a weapon to undermine the authority
of women supervisors, managers, and tutors.
While it is true that R.A. 7877 mandates that committees on decorum and
investigation of cases of sexual harassment should be created in work-
places, in the final analysis the problem will only be resolved if accompa-
nied by positive steps to achieve equality for women in employment. Ef-
fecting positive changes in response to the legal and social recognition of
sexual harassment is within the scope of occupational health nursing. On
a personal level, the occupational health nurse is in a position of trust and
may be the first person with whom an employee discusses the circum-
stances. On a system level, she can participate by helping establish a work
environment that conforms to the current legal mandates. This can be
accomplished by participating in policy development, grievance processes,
and designing guidelines on appropriate or inappropriate conduct in the
workplace. But, of course, the first and foremost objective in the effective
management of sexual harassment is its prevention.
However, one of the drawbacks towards these ends is the fact that women
are often reluctant to report harassment. Women victims should be aware
that their claim of sexual harassment would be strengthened if a timely
complaint or protest against the harasser is made. Fortunately, all the
publicity about sexual harassment has emboldened women who have
previously been unwilling to file complaints to come forward and protest.
Sexual harassment is a social evil. Women should not be conditioned into

accepting it as part of their everyday lives. Indeed, sexual harassment will
continue to be a pervasive problem throughout society, unless women
themselves find the courage to speak out and say, “Enough is enough.”
UP Open University
Violence Against Women:

How Nurses Can Intervene
Henderson and Ericksen (1994) claim that nurses should and can be the
most effective professionals working with abused women. I would like to
believe that this is true. But I also think that it would really take some time
and effort before nurses can really become “battered women specialists.”
So much more awareness, support, and education are needed if nurses
want to help break the “intergenerational transmission of violence.”
For one, nurses themselves have their own myths and fears about abuse
and rape. They are also afraid that they would do more harm than good.
Nurses may perceive their desire to intervene as an “intrusion to a person’s
privacy.” They feel inadequate and incompetent because they are really
inadequate and incompetent to handle actual cases of violence!
In no other issue about women are networking and advocacy more criti-
cal and valuable than in psychosocial problems. The problem may be so
highly private and personal that most women are more likely to keep it to
themselves. Even if they finally muster enough courage to come out in the
open, they do so only to very close friends and family. They firmly refuse
to go to a hospital for medical examination, or to a police station to com-
plain. Which is, of course, understandable.
It is therefore incumbent on the nurse to be aware of government and

non-government agencies servicing women in especially difficult circum-
stances. Working closely with the Department of Social Work and Devel-
opment is also valuable. I believe the more difficult task is really case find-
ing. That a nurse should constantly keep her mouth, nose, eyes, and ears
open is not only easier said than done, but should also be carried out with
caution. It takes a special breed of nurses to do advocacy work for women
with psychosocial problems.
Clinical forensic nursing is one model that has to be developed in our

country. With the increasing incidence of violence against women, nurses
should start re-thinking their stand against violence not merely as a social
problem. Sheridan (1993) says there seems to be a “communication gap
between criminal justice agencies and health care institutions.” What I
can see here is that there is definitely a need for interdisciplinary ap-
proaches to address violence against women. Nurses can, of course, be an
integral part in spearheading these multidisciplinary approaches.
Some countries already have “family violence nurse clinical specialists”

who have a working knowledge of a wide range of criminal and civil
laws. They do mandatory reporting of wife-, elderly-, and child-abuse.
Forensic nurses provide information on how battered women can obtain
UP Open University
Module 17 479
orders of protection and what crisis centers to seek shelter from. They
provide valuable advocacy and support to battered women within the
legal system. Needless to say, assessment is truly a very important aspect
of forensic nursing. History-taking is crucial, as much as thorough and
verbatim documentation. This is one type of “charting” when photographs
should not only be attached but true to its actual situation.
Indeed, domestic violence clinical forensics as a field of specialization is

practically unknown in the Philippines. In fact I know of no Filipino nurse
so far who has received any formal training in the principles of clinical
forensics and forensic nursing. Does this mean, therefore, that Filipino
nurses cannot do anything at all about violence against women? I do not
think so.
With or without formal training, nurses have a unique role in easing the
pain of violence. Listening, sharing personal reactions, and offering other
emotional support, as well as attending to the victim’s physical needs, are
good enough. Have you heard of the rape trauma syndrome? This is the
process of adapting to, and coping with the fear, sense of helplessness,
vulnerability and other emotions rape victims experience. I believe these
emotions are not specific to rape victims alone. Any woman who has
been violated, physically, mentally, or emotionally, will go through the
same emotions. And therefore, any nurse can offer honest empathy and
nonjudgmental listening as long as she does the following:
1. Make herself available. Ask if the victim has a support person. En-
courage a call to some crisis center.
2. Keep the victim comfortable to increase her sense of security. A

woman who has been victimized is afraid to be alone.
3. Tell her what to expect. Let her know that her feelings and reactions
are “normal.” Assure her that she is safe. You may need to share your
own feelings. If you feel angry that it happened, tell her. Your anger
will confirm for the victim that people care about her enough to be
upset that she has been hurt. You can even tell her that you have
difficulty dealing with what she has gone through. She will appreci-
ate your honesty.
4. Encourage her to talk. You don’t have to ask probing questions. Just
coax her to talk about the experience. Being listened to helps the vic-
tim gain self-control by being accepted by others.
A nurse’s role in violence against women cannot be overestimated. One

cannot help but notice, though, that after all, CARING is really what
nursing is all about! You can refer to the accompanying reader for a list of
agencies dealing with domestic violence/abuse.
UP Open University
480 N230 Primary Care for Women
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UP Open University
PRESENT PREGNANCY
= IM M E D IA T E R E F E R R A L T O H O S P IT A L
= R E F E R R A L T O P H Y S IC IA N /R H U
L M P : m o n th day ye a r E D C : m o n th day year
T R IM E S T E R 1ST 2ND 3RD
A O G IN M O N T H S 2 OR 3 4 5 6 7 8 9
D A T E O F T H IS V IS IT
V A G IN A L B L E E D IN G (Y /N ) H
U R IN A R Y T R A C T IN F E C T IO N (Y /N )
W E IG H T IN K G .
BLOOD PRESSURE
B P 1 4 0 /9 0 A N D A B O V E (Y /N ) H
F E V E R 3 8 O C A N D A B O V E (Y /N )
P A L L O R (Y /N )
H
A B N O R M A L F U N D A L H E IG H T (Y /N ) 20 2 1 -2 4 2 5 -2 8 2 8 -3 0
3 0 -3 4 C M S
CMS CMS CMS CMS
A B N O R M A L P R E S E N T A T IO N (Y /N ) H
M IS S IN G F E T A L H E A R T B E A T (Y /N ) H
E D E M A (Y /N )
V A G IN A L IN F E C T IO N (Y /N )
LA B TE ST R E SU LTS
(e .g ., H G B , U R IN E , V D R L )
A C T IO N
IR O N /F O L A T E # /R X
IO D IN E S U P P L E M E N T A T IO N IN H IG H R IS K
A R E A S (Y /N )
M A L A R IA P R O P H Y L A X IS (Y /N )
M O T H E R IN T E N D S T O B R E A S T F E E D ? (Y /N )
A D V IC E O N 4 D A N G E R S IG N S (Y /N )
D E N T A L C H E C K -U P ? (Y /N )
E M E R G E N C Y P L A N S A N D P L A C E O F D E L IV E R Y
(Y /N )
R IS K ? (Y /N )
D A T E O F N E X T V IS IT
L A B O R & D E L IV E R Y :
IM M E D IA T E B R E A S T F E E D IN G (Y /N ) B IR T H W E IG H T IN G R A M S
T Y P E O F D E L IV E R Y P O S T -P A R T U M H E M O R R H A G E 5 0 0 C C + (Y /N )
D A T E O F D E L IV E R Y B A B Y A L IV E (Y /N )
P L A C E O F D E L IV E R Y B A B Y H E A L T H Y (Y /N )
B IR T H A T T E N D A N T (M D , N U R S E , M ID W IF E ,
U N T R A IN E D H IL O T , T R A IN E D H IL O T , O T H E R S ) M A L A R IA P R O P H Y L A X IS :
C H L O R O Q U IN E 1 5 0 m g b a s e
p e r ta b le t, 2 ta b le ts p e r w e e k
4 S IG N S O F D A N G E R D U R IN G P R E G N A N C Y :
1 .) A N Y T Y P E O F V A G IN A L B L E E D IN G
2 .) H E A D A C H E , D IZ Z IN E S S , B L U R R E D V IS IO N
3 .) P U F F IN E S S O F T H E F A C E A N D H A N D S IR O N F O L A T E :
4 .) B E IN G P A L E O R A N E M IC 6 0 m g ta b le t, 2 ta b le ts d a ily fo r
*W rite Y e s o r N o in a p p ro p ria te s p a c e s 125 days
PANEL 3 PANEL 4 PANEL 1
POSTPARTUM CARE
REPUBLIC OF THE PHILIPPINES
REFERRAL: Q.C HEALTH DEPARTMENT
Y = YES N = NO
PROBLEMS IDENTIFIED AND ACTION TAKEN BY THE MIDWIFE REFER TO HOSPITAL HOME BASED MOTHER’S RECORD
(INDICATED DATE) ALWAYS BRING THIS CARD WHEN YOU VISIT A HEALTH
REFER TO PHYSICIAN/RHU FACILITY
HOME VISIT
BLOOD TYPE _______________ FAMILY SERIAL NO. _______________
TIMING OF POST- 24 2-4 CLINIC
1 WEEK
PARTUM VISIT HOURS WEEKS VISIT
DATE OF VISIT NAME: _______________________________________________________

ADDRESS: ____________________________________________________
EXCLUSIVE ____________________________________________________
BREASTFEEDING (Y/N)
INTENDS TO USE FAMILY

DATE TETANUS 1 2 3
PLANNING (Y/N)
4 5
TOXOID GIVEN
FEVER 38oC AND
ABOVE (Y/N)
AGE: ________ yr. below 18 18-34 35+
FOUL SMELLING VAGINAL HEIGHT: ________ yr. below 145cm 145 cm. & above
DISCHARGE (Y/N)
EXCESSIVE VAGINAL OBSTETRICAL HISTORY

BLEEDING (Y/N)
(FINDINGS ACTIONS TAKEN AND INSTRUCTIONS NUMBER OF
0 1 2 3 *4 + H
FROM REFERRAL CENTER) PALLOR (Y/N) PREVIOUS PREGNANCIES
CORD OK? (Y/N)

PREVIOUS CAESAREAN SECTION NO YES H
VITAMIN A 200,000 IU Y/N 3 CONSECUTIVE MISCARRIAGES NO YES
IRON/FOLATE DATE/# STILLBIRTH NO YES
POST-PARTUM HEMORRHAGE NO YES H

BREASTFEEDING IS BEST FOR BABY. SPACING BIRTHS MORE
THAN 24 MONTHS APART WILL ENSURE YOUR HEALTH AND THE
HEALTH OF YOUR CHILDREN. PRESENT HEALTH PROBLEMS:
TUBERCULOSIS (14 DAYS + OF COUGH) NO YES
FAMILY PLANNING
HEART DISEASE NO YES H
DATE OF DATE OF QUANTITY
METHOD REMARKS H
FOLLOW UP VISIT GIVEN DIABETES NO YES
BRONCHIAL ASTHMA NO YES H
GOITER YES
= REFER TO PHYSICIAN/RHU (AND FOLLOW UP)

= CLOSE OBSERVATION OR ACTION BY MIDWIFE
H = HOSPITAL DELIVERY RECOMMENDED
* You may wish to consider a permanent method of Family Planning.

Encircle appropriate answer.

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Module 15

Advances in Diagnosis and

S ince the first successful vaginal artificial in-

achieved in the majority of patients. According to the World Health Or-

Female cases of infertility has a higher incidence than that of males in

In women, the most common cause of infertility is disease of the fallopian

Ovulatory disorders also rank high as a cause of infertility (17.9% in de-

Sub-Saharan African Developed

Bilateral Tubal Occlusion 41.9 1 10.6 3

Bilateral tubal occlusion

Figure 15-1. Distribution of most common specific

Ovulatory disorders No demonstrable

Figure 15-2. Distribution of most common specific

Blood test for chlamydial infection

It is difficult to culture chlamydia. Thus, the research activities of WHO

Laparoscopy with hydratubation

Magnetic Resonance Imaging (MRI)

Chlamydial Vaccine Research

The major protein in the outer membrane of the organism of chlamydia

1. Obstructed __________ __________ __________

Management of Female Infertility

Ovarian stimulation is done through the use of drugs like Clomiphene

limitations. Two of these limitations are: inhibitions of endometrial devel-

Bromocriptine mesylate is a potent dopamine receptor agonist that in-

A serious complication of ovarian stimulation is the formation of multiple

Now, let’s consider the non-pharmacologic interventions in female infer-

Oocyte and embryo cryopreservation

The maternal and perinatal risks of high multiple pregnancy following

Another approach involves the microinjection of a number of spermato-

Assisted Reproductive Technologies (ART)

Gamete Intra-Fallopian Transfer Techniques (GIFT)

procedure is repeated in the opposite tube, if possible. Follicular fluid has

Zygote Intra-Fallopian Transfer (ZIFT)

In 1986, Devroey et al., reported the occurrence of pregnancy after

Efficacy of Assisted Reproductive Technologies (ART)

Questions have been raised regarding the efficacy of assisted reproduc-

Other improvements in ART includes assessment of the uterine environ-

Only about 65% of all pregnancies achieved by in-vitro fertilization have

The incidence of spontaneous abortions following natural fertilization has

Ectopic or extra-uterine pregnancy is one of the major complications of

Heterotopic pregnancy (concomitant ectopic and intra-uterine pregnancy)

Chromosomal anomalies represent the major cause of embryonic loss

Treatment of Male Infertility

Hormonal and surgical treatment

Artificial insemination with the husband’s/partner’s whole ejaculate is

Now, you have read the advances in assisted reproductive technologies

The fields of human genetics and assisted reproductive technologies are

The nurse as a coordinator of services

The nurse as a counselor and health educator

ally stressful because it is a reminder of the person’s fertility problem and

Remaining sensitive to a patient’s need for supportive comments, reassur-

The nurse as a client advocate

Discuss the feasibility of using the reproductive technologies pre-

Assisted reproductive technologies (ART) have been developing rapidly.

The nurse needs to be knowledgeable regarding these advances in ART so

Answers to Self-Assessment Questions (ASAQ)

Bilateral tubal occlusion 41.9 1 10.6 5

Obstructed fallopian tubes 3

Laparascopy with hydratubation is useful for conditions found in the pelvic

2. Zygote Intra-Fallopian Transfer (ZIFT) — the mature oocytes are ob-

3. Pro-Nuclear Stage Transfer (PROST) - the procedure is very much like

N owadays, diseases like cancer, diabetes or

1. Obstructed __