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 DEFINITION
Fertility is defined as the capacity to
conceive or reproduce.

Infertility is defined as a failure to

conceive within one or more years of
regular unprotected coitus.

Infertility is the inability to achieve

conception after one year of
unprotected intercourse.
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 INCIDENCE
According to statistics by the Centers for
Disease Control (CDC)

6.1 million women between the ages of

15 to 44 have an impaired ability to have
children.

2.1 million married couples are

experiencing infertility.

9.2 million women had made use of

infertility services.
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 INCIDENCE ..Contd.
WHO survey report 2000 reveals
Incidence of infertility as 12-13.5 %
among married couples.

80 % of the couples achieve

conception within one year of regular
intercourse ( 4-5 times in a week )

10 % will achieve by the end of 2nd year

10 % will remain infertile by the end of

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2nd year. 5
 TYPES OF INFERTILITY

1. PRIMARY INFERTILITY
When a couple has never been pregnant
either the woman has never conceived or
the man has never fathered a child.

2. SECONDARY INFERTILITY
Secondary infertility refers to women who
have achieved pregnancy and given birth
in the past, but are now having difficulty
conceiving.
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TYPES OF INFERTILITY..Contd.

3. IDIOPATHIC INFERTILITY
No definite cause for the infertility can be
found.

4. RECURRENT MISCARRIAGE
Women who experience recurrent
miscarriage may also receive a diagnosis
of infertility if they experience two or more
successive miscarriages.

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 CAUSES OF INFERTILITY

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CAUSES OF INFERTILITY

1. ENDOMETRIOSIS

1/3rd of infertile women have endometriosis

Endometrial tissue outside of uterus

Anatomic distortion, adhesions

Ovarian damage (endometrioma)

Substances that impair ovulation, fertility,

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implantation 9
 CAUSES OF
INFERTILITY
Cont....
2. TUBAL BLOCKAGE

Due to PID because it leaves scar tissue

& adhesions as a result of inflammation
tubes may be kinked or twisted.

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CAUSES OF INFERTILITY Cont....

3. PREVIOUS SURGERY
Previous surgery like appendectomy,
repair of a tube after ectopic pregnancy
may cause adhesions or scaring.

4. Use of IUD or progesterone only oral

contraceptives increases risk of ectopic
pregnancy.

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 CAUSES OF INFERTILITY Cont....

5.OVULATION ANOMALIES (ANOVULATION )

Failure of the ovaries to produce, mature or

release eggs is an imbalance of harmones.

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 CAUSES OF INFERTILITY Cont....

6. CERVICAL MUCOUS PROBLEMS

Hormonal deficiencies that maintain the

thick acidic property of cervical mucus
so it is hostile to sperm.

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 CAUSES OF INFERTILITY Cont....

7. INSUFFICIENT OESTROGEN &

PROGESTERONE PRODUCTION
Excessive androgen production, increased or
decreased FSH, LH Levels. The production FSH
stimulates follicle to ripen & causes the
production of Progesterone. Production of
estrogen is influenced by the levels of circulating
prolactine from the pituitary gland.

8. IMMUNOLOGIC FACTORS
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 CAUSES OF INFERTILITY Cont....

9.VARICOCELE
Is a varicose or swollen vein in the
testicle. Swelling elevates the temperature
within the testis. It retards or destroys the
process of spermatogenesis.
INCIDENCE 35 % in the infertile population.

10.COMBINED CAUSES

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 FACTORS RESPONSIBLE FOR
INFERTILITY
1. Coital frequency
2. Age
3. Smoking
4. Exercise and weight loss
5. Diet
6. Stress
7. Medical conditions
8. Use of drugs and chemicals
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 FACTORS RELATED TO SPERM
AND OVULATION
1. Healthy spermatozoa ( male factor )
2. The spermatozoa should undergo
changes(capacitation,acrosome reaction )
and acquire motility. ( Cervical factor )
3. The motile spermatozoa should ascend
through the cervix into the uterine cavity
and the fallopian tubes.
4 There should be ovulation.(Ovarian factor )
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 FACTORS RELATED TO SPERM
AND OVULATION . Contd.
5. The fallopian tubes should be patent and the
oocyte should be picked up by the fimbriated
end of the tube. ( Tubal factor )

6. The spermatozoa should fertilize the oocyte at

the ampulla of the tube.

7. The embryo should reach the uterine cavity

after 3-4 days of fertilization.

8. The endometrium should be receptive for

implantation and the corpus Luteum should18
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function adequately.
INVESTIGATIONS OF INFERTILITY
Objectives of investigations

To detect the etiological factors.

To rectify the abnormality in an

attempt to improve the fertility.

To give assurance with explanation to

the couple if no abnormality is detected.
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 BASIC INVESTIGATIONS
MALE
1. HISTORY
Age duration of marriage,history of
previous marriage
General medical history
Surgical history
Occupational history
Sexual history
Social habits

2. EXAMINATION
General and specific examination

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Seminal fluid analysis 20
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 BASIC INVESTIGATIONS Contd

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 BASIC INVESTIGATIONS Contd

Normal semen values

Volume 2.0 ml or more
PH 7.2 7.8
Sperm concentration 20 million / ml or more
Total sperm count > 40 million per ejaculate
Motility 50 % or more progressive
forward motility
Morphology 15 percent or more
normal form
Viability 75 % or more living
Leucocytes Less than 1 million / ml
Sperm agglutination < 2 ( scale 0-3 )
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 BASIC INVESTIGATIONS Contd
MALE
3. INDEPTH EVALUATION
Serum FSH, LH, Testosterone, Prolactin
and TSH
Fructose content in the seminal fluid
Testicular biopsy

4. TRANSRECTAL ULTRASOUND ( TRUS )

5. VASOGRAM

6. IMMUNOLOGICAL TEST
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 BASIC INVESTIGATIONS
FEMALE
1. HISTORY
General medical history
Surgical history
Menstrual history
Previous obstetric history
Contraceptive practice
Sexual problems

2. EXAMINATION
General and specific examination
Gynaecological examination

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Speculam examination 24
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 BASIC INVESTIGATIONS Contd
3 CONFIRMATION OF OVULATION
The various methods used to detect are indirect,direct and
conclusive.

A. Indirect

B. Direct

C. Conclusive

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 BASIC INVESTIGATIONS Contd..
Indirect causes are
i. Menstrual history
ii. Basal Body Temperature ( BBT ) Assessment

Temp to be taken with a special thermometer every

morning before getting out of bed.
BBT increases slightly at ovulation & remain
increased until menstruation or pregnancy.
BBTS are taken in same manner as for fertility control.
Evidence of follicle development, ovulation & corpus
luteum development would be seen if temperature
changes persisted for 12-14 days before menses.
Temperature chart for at least 4 cycles.
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 BASIC INVESTIGATIONS Contd

iii. Cervical mucus study

After ovulation the cervical mucus becomes thick
& sticky and can be stretched between the
fingers.( A sign known as spinbarkeit )

If the mucus is mixed with semen or contraceptive

foams or an infection is present, the result may be
inaccurate. Some women may feel uncomfortable
touching their genitals and mucus.

Cervical mucus examined at ovulation & after

intercourse to determine whether changes occur
that promote sperm penetration & cervical.
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BASIC INVESTIGATIONS Contd
Postcotial test (Sims-Huhner)
Intercourse (2-12 hrs) for test Look at: pH, Sperm,
Spinnbarkeit, Ferning Cellularity, Sperm Shaking,
Sperm Agglutanation

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 BASIC INVESTIGATIONS Contd

iv. Hormone estimation

Testicular dysfunction causes rise in

FSH and LH.

Low level of FSH and LH suggest

hypogonado trophic gonadism.

Eleveted prolactin due to pituitary

adenoma may cause impotency.
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 BASIC INVESTIGATIONS Contd

v. Vaginal Cytology

Maturation index shifts to the left from the

midcycle to the midsecond half of cycle
due to the effect of progesterone.

vi. Endometrial Biopsy

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 BASIC INVESTIGATIONS Contd
vii. Sonography
Serial sonography during midcycle measures
the graafian follicle before ovulation(18 to 20 mm)
Features of ovulation seen are collapsed follicle
and fluid in the pouch of douglas.
Hysteriosalphigiography To rule out uterine or
tubal abnormalities.

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BASIC INVESTIGATIONS Contd

B. Direct - laproscopy

C Conclusive - Pregnancy

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 ADVANCED MANAGEMENT OF INFERTILITY
COUPLE INSTRUCTIONS
Assurance Body weight
Smoking and Alcohol Coital problems
MALE INFERTILITY TREATMENT
1. General care
Counselling Use of vitamins E, C, D, B12.
Medications like Clomiphene citrate 25 to 50 mg
orally for 25 days with rest for 5 days for 3
cycles. It increases of sr level of FSH, LH and
testosterone.
In genetic abnormality artificial insemination of
donor sperms.
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ADVANCED MANAGEMENT OF INFERTILITY
Contd
MALE INFERTILITY TREATMENT
2. Surgical care
Microsurgeries like vasoepididymostomy
or vasovasostomy if patient is azoospermic.
Correction of varicocele
Orchidopexy in undescended testies

3. Impotency
Psychosexual treatment
For erectile dysfunction sildenafil (25 to 100mg

4. Assisted reproductive technology ( ART )

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ADVANCED MANAGEMENT OF INFERTILITY
Contd
FEMALE INFERTILITY TREATMENT
1. General care
Psychotherapy
Reduction of weight

2. Drugs
Medications like Clomiphene citrate 50 mg
to 250 mg orally for 5 days for 6 cycles. It
blocks the estrogen receptors in the
hypothalamus
In genetic abnormality artificial insemination
of donor sperms.
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ADVANCED MANAGEMENT OF INFERTILITY
Contd
FEMALE INFERTILITY TREATMENT

3. Surgery

Laproscopic ovarian drilling ( LOD )

Tubal surgeries
Uterovaginal surgeries

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 ASSISTED REPRODUCTIVE TECHNOLOGY

1.Intrauterine insemination ( IUI )

IUI may be either AIH ( Artificial

insemination Husband ) or AD (Artificial
insemination of donor or a combination of
both.

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 ASSISTED REPRODUCTIVE TECHNOLOGY
Contd
2. Gamete intrafallopian transfer ( GIFT )
Both the sperm and unfertilised oocytes are
transferred into the fellopian tubes.

3. Zygote intrafallopian transfer ( ZIFT )

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 ASSISTED REPRODUCTIVE TECHNOLOGY
Contd
INVITRO FERTILIZATION ( IVF)

IVF or In Vitro Fertilization is a method of

assisted reproduction to increase the
possibility of pregnancy.

As the term in vitro fertilization or test

tube baby explains itself, it is the
procedure to fertilize eggs with sperm
outside the human body.
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 ASSISTED REPRODUCTIVE TECHNOLOGY
Contd

INDICATIONS OF IVF

Blocked or damaged fallopian tubes

Abnormal sperm,
Endometriosis or immunologic problems,
other infertility treatment,
Advanced maternal age.

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 ASSISTED REPRODUCTIVE TECHNOLOGY
Contd
Procdures of IVF & ET
1. Controlled Superovulation (COH)
(Clomiphene, hMG, uFSH, rFSH )
2. Monitoring (Ultrasound, E2)
3. Egg retrieval & IVF (or ICSI)
4. Embryo culture
5. Embryo Transfer (ET)
6. Luteal phase support (progesterone)
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 ASSISTED REPRODUCTIVE TECHNOLOGY
2. Ultrasound monitoring of follicles Contd

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ASSISTED REPRODUCTIVE TECHNOLOGY Contd.

3. Ultrasound Guided Oocyte Retrieval

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 ASSISTED REPRODUCTIVE TECHNOLOGY
Embryo Culture Contd

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 ASSISTED REPRODUCTIVE TECHNOLOGY
Contd
5. Embryo Transfer

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ASSISTED REPRODUCTIVE TECHNOLOGY Contd

Intracytoplasmic sperm injection (ICSI)

ICSI is a highly technical procedure designed to

insert a sperm into the cytoplasm of egg using a
thin glass tube under the special microscope
with a manipulator.
Indications:
Severe male factor infertility
Poor quality eggs with thickened shell (zona)
Prior or repeated fertilization failure with standard
IVF
Anti-sperm antibodies
Use of surgically retrieved sperm directly from the
epididymis or testis
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ASSISTED REPRODUCTIVE TECHNOLOGY Contd

Intracytoplasmic sperm injection (ICSI)

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 ALTERNATIVES TO INFERTILITY

1. Surrogacy
Embryos are transferred to the uterus of
another woman who is willing to carry the
pregnancy on behalf of the infertile
couple.
2. Adoption

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 ETHICAL AND LEGAL ISSUES IN
INFERTILITY
1. Artificial insemination by donor
Proper consent of her husband is taken.
2. Surrogacy
Proper consent of surrogate mother is taken.
Total responsibility of rearing parents if child
born with birth defects.
3. Frozen embryo
Should not be bought or sold.
4. Issues related to donor insemination
Use of only one donor for each attempt.
Proper consent and contract accepting the
resultant offspring as legal heir.
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 APPLICATION OF NURSING THEORY
HILEGARD E. PEPLAU
THEORY OF INTERPERPERSONAL RELATION

Details of the Hildegard

Born in Pennsylvania in 1909. Started her
carrier from a diploma nursing program in 1931.
1947 MA in psychiatric nursing from Colombia
University, Newyork.
1953 Published book on interpersonal
relationship in nursing.
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 APPLICATION OF NURSING THEORY Contd.

In 1974 got retired & was recognized all

over as a nurse.

Nursing can be viewed as an interpersonal

process as it involves interaction between
two or more individual with a common goal.

For developing interaction between nurse

and patient the nurse has to choose
sequential pattern and different skills and
assume various roles etc.
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 APPLICATION OF NURSING THEORY Contd

Four phases in interpernal relationship by peplau

Orientation : Problem defining phase.

Identification : Selection of appropriate
professional assistance.
Exploitation : Use of assistance for
problem solving.
Resolution : Termination of professional
relationship
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 ROLE OF A NURSE IN INFERTILITY
MANAGEMENT
1. Involved with couples who undergoing
fertility treatment.
2. Should be aware of the types of treatment
that are currently available and stresses
that the couple has endured during the
process.
3. Reduce stress in relationship
4 Encourage co-operation, protect privacy.
5 Refer couple to appropriate resource
when necessary.
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 ROLE OF A NURSE IN INFERTILITY
MANAGEMENT Contd
6. Advice to couple to avoid smoking
7. Emphasis on diet, exercise, stress
reduction techniques, health
maintenance and disease prevention
programs.
8. Psychological support
9. Assist with different infertility
treatments.
10. Create awareness about ethical and
legal issues.
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 NURSING PROCESS
1. Altered health maintenance related to
ineffective coping mechanisms in one or
both partners.
2. Self-esteem disturbances related to loss of
reproductive abilities.
3. Knowledge deficit related to menstrual
cycle, sexual physiology.
4. Knowledge deficit related to advance
management of infertility.
5. Altered sexual pattens related to treatment
procedures.
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