INFERTILITY

• Inability conceive a child or sustain a

pregnancy to childbirth.
• Exist when a pregnancy has not occured
after at least 1 year of engaging in
unprotected coitus.
Types:
• PRIMARY INFERTILITY
– There have been no previous conception
• SECONDARY INFERTILITY
– There has been a previous viable pregnancy
but the couple is unable to conceive at present
MALE INFERTILITY FACTORS
MALE IFERTILITY FACTORS
1. Disturbance in spermatogenesis
2. Obstruction in the seminiferous tubules,
ducts, or vessels preventing movement of
spermatozoa
3. Qualitative or quantitative changes in the
seminal fluid preventing sperm motility
3. Development of autoimmunity that
immbolizes sperm
4. Problems in ejaculation or deposition
preventing spematozoa from being placed
close enough to the woman’s cervix to
allow ready penetration and fertilization.
INADEQUATE SPERM COUNT
• Sperm Count
– Number of sperm in a single ejaculation or
milliliter of smen
– N: 20M/mL of seminal fluid or 50M/ejaculation
• Factors that can affect sperm count:
– Any condition that significantly increases body
termperature
– congenital abnormalities
– Twisted spermatic cord
– Varicocele
– Trauma to the testes
– Endocrine imbalances
– Surgery on or near the testes
– Drug or excessive alcohol use
– Excessive exposure to x-ray or radioactive
substances
– Sons with women who took diethylstilbestrol
OBSTRUCTION OR IMPAIRED SPERM
MOTILITY

• Occur at any point along the pathway that

spermatozoa must travel to reach the
outside.
• Causes:
– Mumps orchitis
– Epididymitis
– Tubal infections (gonorrhea or ascending
urethral infection)
– Congenital stricture of the spermatic duct
– Hypertrophy of the prostate gland
– Infection anywhere in the reproductive tract
– Anomalies of the penis
EJACULATION PROBLEMS
Causes:
• Erectile dysfunction (impotence)
– Psychological problems
– Debilitating diseases
– medications
• Premature ejaculation
FEMALE INFERTILITY
FACTORS
1. Anovulation
2. Problems of ova transport
3. Uterine factors
4. Cervical and vaginal factors
ANOVULATION
• Absence of ovulation
• Most common casue of infertility in women
• Causes:
– Hypogonadism
– Hormonal imbalance
– Ovarian tumors
– Exposure to x-rays or radioactive substances
– General ill health
– Poor diet
– stress
– Decreased body weight or body/fat ratio or less
than 10%
TUBAL TRANSPORT PROBLEMS
• Usually due to scarring of the fallopian
tubes
– PID
• Infection of pelvic organs usually caused by
chlamydia and gonorrhea
– Ruptured AP
– Abdominal surgery involving infection
UTERINE PROBLEMS
• Tumors
– Block the entrance of the fallopian tubes OR
– Limit space available for effective implantation
• Uterine deviations
• Poor secretions of estrogen and
progesterone
• Endometriosis
– Implantation of uterine endometrium, or
nodules, that have spread from the interior of
the uterus to locations outside the uterus
• Cul-de-sac of douglas
• Ovaries
• Uterine ligament
• Outer surface of the uterus
• bowel
CERVICAL PROBLEMS
• causes:
– Infection and inflammation of the cervix
– Stenotic cervical os
• Congenital
• Scarring from D&C and/or cervical
surgeries.
– Obstruction of the cervix (e.g. Polyp)
VAGINAL PROBLEMS
• Causes:
– Infection of the vagina
– Presence of sperm antibodies
FERTILITY ASSESSMENT
Schedule:
• Woman is younger than 35
– 1 year of infertility
• Woman above 35
– 6 months of infertility
HISTORY
• Husband:
– General health
– Nutrition
– Alcohol, drug, or tobacco use
– Congenital health problems (hypospadia,
cryptorchidism)
– Illnesses (mumps, UTI, STDs)
– Operations on or near the Reproductive Tract
– Current illnesses (endocrine illnesses)
– Past and current occupation and work habits
– Sexual practices:
• Frequency of coitus and masturbation
• Failure to achieve ejaculation
• Premature ejaculation
• Coital positions used
• Existence of any children from previous
relationships
• Female
– Infections in the reproductive tract
– Overall health
– Abdominal or pelvic opeartions
– Use of douches or intravaginal medication or
sprays
– Exposure to occupational hazards
– Nutrition
– Symptoms of ovulation
– Menstrual history
• Age of menarche
• Length, regularity, and frequency of
menstrual flow
• Amount of flow
• Difficulties experienced
• History of contraceptive use
• History of any pregnancies and abortion
PHYSICAL ASSESSMENT
• Inspect for secondary sexual
characteristics and genital abnormalities
FERTILITY TESTING
SEMEN ANALYSIS
• Done 2 – 4 days of sexual abstinence
• Spermatozoa are examined under a
microscope within 1 hour of collection
noting appearance and motility
– N: 2.5 – 5 mL pf semen
Minimum of 20 M sperms/mL (50 –
200 M/mL)
• Repeated in 2 – 3 months
• SPERM PENETRATION ASSAY AND
ANTISPERM ANTIBODY TESTSING
• OVULATION DETERMINATION BY
BASAL BODY TEMPERATURE
• OVULATION DETERMINATION BY TEST
STRIP
• OVULATION DETERMINATION BY
CERVICAL MUCUS ASSESSMENT
– FERN TEST
– SPINNBARKEIT TEST
• POSTCOITAL TEST
– Combines both ovulation detection and semen
analysis
– Couple will have coitus during time of ovulation
and then the woman reports to the health care
facility within 2 or 8 hours.
– Shows the presence of sperm and how they
interact with the woman’s vaginal and cervical
environment
• ULTRASONOGRAPHY AND X-RAY
IMAGING
– Determine the patency of the fallopian tube and
assess the depth and consistency of the
endometrial lining
– Sonohysterography
• Ultrasound technique for inspecting the
uterus
– Hysterosalpingography
• Radiologic examination of the fallopian
tubes using a radioopaque medium
SURGICAL EVALUATION
Uterine Endometrial Biopsy
• Used as a test for ovulation or to reveal an
endometrial problem such as luteal phase
defect.
• Cork-screw appearance  + for
ovulation
• Done 2 – 3 days before the expected
menstrual flow.
• Complications:
– Bleeding
– pain
– Infection
– Uterine perforation
• Nursing Responsibilities
– caution client to expect small amount of vaginal
spotting after the procedure
– Instruct client to contact physician if she
develops a temperature more than 38C, has a
large amount of bleeding, or passes clots
– Advise woman to inform physician when she
has her next menstrual flow  for accurate
results
Hysteroscopy
• Visual inspection of the uterus through the
insertion of a hysteroscope through the
cervix
• Helpful in discovering uterine adhesions
Laparoscopy
• Introduction of a thin, flexible lighted tube
(laparoscope) through a small incision in
the abdomen just above the umbilicus to
examine the position and state of the
fallopian tubes and ovaries.
• Done during the follicular phase of the
menstrual cyle and done under general
anesthesia
• Used to view proximity of the ovaries to
the fallopian tubes.
• Procedure
– Patient place in trendelenburg position
– Carbon dioxide is introduced into the abdomen
• Women may feel a bloating of the abdomen
after the procedure
• Sharp shoulder pain  if CO2 escapes
under the diaphragm
• Dye can be injected into the uterus to
assess tubal patency
– If dye appears in the abdominal cavity  tubes
are patent.
INFERTILITY MANAGEMENT
CORRECTION OF
UNDERLYING PROBLEM
Increasing Sperm Count and
Motility
• Low Sperm Count
– Man is advised to abstain from coitus 7 – 10
days to increase the amount
– Ligation of a varicocele
– Lifestyle changes
• Wearing looser clothing
• Avoiding long periods of sitting
• Avoid prolonged hot baths
– Medications
• Clomiphene citrate
• Aromatase inhibitors
• Testosterone and HCG
• Spermatozoa is immbolized
– Used of corticosteroid of the woman to
decrease immune response and antibody
production
Reducing the Presence of Infection
• Treat infection according to the causative
organism based on culture reports
Hormone Therapy
• Clomiphene citrate
– DOC to stimulate ovulation
• Human Menopausal Gonadotrophin
– Stimulate ovulation
• Bromocriptine
– Given if patient has increased prolactin levels
• Disadvantage Clomiphene and hMG
– Produce multiple births  meds may
overstimulate ovaries
• Conjugated Estrogen
– Given to alter cervical mucus secretions
• Progesterone vaginal suppositories
– If problem is a luteal phase defect
SURGERY
• myomectomy
– Done if myoma is interfering with fertility
• Lysis of uterine adhesions
• Diathermy
– If problem is tubal insufficiency
• Canalization of the fallopian tubes
– if problem is tubal insufficiency
ASSISTED REPRODUCTIVE
TECHNIQUES
Artificial Insemination
• Instillation of sperm into the female
reproductive tract to aid conception
• Types according to location of
instillation:
– Intracervical insemination
– Intrauterine insemination
• Types according to donor:
– Artificial insemination by husban
– Artificial insemination by donor (therapeutic
donor insemination)
• Indications
– Man has inadequate sperm count
– Woman has vaginal or cervical factor interfering
with sperm motility
– If man has a known genetic disorder that he
does not want ot be transmitted to offspring
– Woman has no male partner
– Families whose husband has undergone
vasectomy and cannot be reverse
• Cryopreserved Sperm
– Frozen sperm
– Sperm banking
– Advantages:
• Donor have no history of disease and no
family of possible inhertibale disorder
• Blood type can be matched with the
woman’s
• Sperm can be selected according to desired
physical or mental characteristics
• Done the day after ovulation
• Takes an average of 6 months to achieve
conception
IN VITRO FERTILIZATION AND EMBRYO
TRANSFER

• IN VITRO FERTILIZATION
– Refers to removing one or more of the mature
oocytes from a woman’s ovary by laparoscopy
and then fertilizing them by exposing them to
sperm under laboratory conditions outside the
woman’s body
• EMBRYO TRANSFER
– “Ova Transfer”
– The insertion of the laboratory-grown fetilized
ovum into the woman’s uterus approximately 40
hours after fertilization
• Indications
– Blocked or damaged fallopian tubes
– Oligospermia
– Absence of cervical mucus
– Presence of antisperm antibodies
– Unexplained infertility
• Recovery rate for harvesting ripened
eggs: 90%
• Ability to fertilized eggs by sperm in
vitro: 90%
• Overall pregnancy rate: 20 – 30%
Gamete Intrafallopian Transfer
• Bothova and sperm are instilled within a
matter of hours using a laparoscopic
technique/ultrsound into the open end of a
patent fallopian tube.
• Contraindicated if the woman’s tubes are
blocked
Zygote Intrafallopian Transfer
• Fertilized eggs are transferred by
laparoscopic technique into the end of the
waiting fallopian tube.
• Contraindicated if the woman’s tubes are
blocked
Surrogate Embryo Transfer
• Assisted rerporducted technique for the
woman who does not ovulate
• Uses egg cell from a donor
Intravaginal Culture
• Uses the woman’s body as an incubator-
like device
• Ova are obtained from the woman and
placed with the sperm in a sterile,
hermetically sealed container of culture
medium
• Container is placed in woman’s vagina
• After 48 hours, the container is opened
and any fertilized dividing effs are
transferred in uteru