BASICINFERTILITY
DEFINITION:
Infertility is defined as the failure of a couple to achieve pregnancy after 12 months or longer of regular unprotected intercourse. The focus of the visit should be to determine potential causes of the inability to achieve pregnancy. The evaluation of both partners should begin at the same time.
Earlier assessment (such as 6 months of regular unprotected intercourse) is justified for:
-Women aged >35 years
-Women with a history of oligomenorrhea (infrequent menstruation)
-Women with known or suspected uterine or tubal disease or endometriosis
-Women with a partner known to be subfertile (condition of being less than normally fertile though still capable of effecting fertilization)
-Men with known risk factors or concerns of fertility potential
SUBJECTIVE:
Mustinclude for Women:
1.Reproductive Life Plan
2.Medical history
a.Allergies
b.Medications
c.Past surgeries, hospitalizations
d.Serious illness or injuries
e.Medical conditions associated with reproductive failure (e.g., thyroid disorder, hirsutism, endocrine disorders)
f.Childhood disorders
g.Gynecology history (cervical cancer screening results)
h.Family history (reproductive failure)
3.Reproductive History/Sexual health assessment
a. How long client has been trying to achieve pregnancy
b. Coital frequency
c. Level of fertility awareness
d. Results of previous evaluation and treatment
e. Gravidity, parity, pregnancy outcome(s) and associated complications
f.Age at menarche, cycle length and characteristics, and onset/severity of dysmenorrhea
4. STD-past and or present exposure-
5.Zika Risk Assessment
a.Travel-self and partner(s)
1) Past travel –last 8 months –where and when
2) Plans for future travel –where and when
Mustinclude for Men:
(Same as above excluding gynecology history and menstrual history)
1.Gonadal toxin exposure, including heat
2.Zika Risk Assessment
Travel-self and partner(s)
a. Past travel –last 8 months –where and when
b. Plans for future travel –where and when
OBJECTIVE:
Candidate for Infertility
LABORATORY:
Male clients concerned about their fertility should be offered a semen analysis via an unpaid laboratory requisition. If this test is abnormal, they should be referred for further diagnosis (i.e., second semen analysis, endocrine evaluation, post-ejaculate urinalysis, or others deemed necessary) and treatment. The semen analysis is the first and most simple screen for male fertility. Consider Zika screening if indicated by Zika Risk Assessment.
ASSESSMENT:
1. Primary Infertility - the couple has never conceived together
Potential causes:
a.Probable anovulatory cycling
b.Probable tubal factor
c.Unproven partner
d.Possible cervical factor
e.Unexplained
fOther
2. Secondary Infertility - difficulty in conceiving with a couple who has conceived together prior
Potential causes:
a. Probable anovulatory cycling
b. Probable tubal factor
c. Possible cervical factor
d. Unexplained
e. Other
PLAN:
Based on Agency Protocol the following may be offered:
1. If menstruating every 21-35 days,may offer progesterone 7 days before next menses.
2. If age >35, mayoffer Cycle Day 3 FSH.
3. If unexplained amenorrhea >6 month, mayoffer FSH, Estradiol.
4. If irregular cycling,may offer TSH, Prolactin.
5. Suggest Chlamydia screenor HSG if tubal factor suspected.
6. Obtain preconception labs (if have not been done in last year): see protocol 6.1.1 Preconception Health).
7. May offer Provera 5-10 mg tabs, 1 tab orally daily x 12 days if she has not had menses in last 35 days and urine pregnancy test negative. Return to provider if no withdrawal bleeding with two weeks after completing medication.
PATIENT EDUCATION:
1.Prenatal vitamins or other source of folic acid for 3 months prior to conception (some patients may need more folate by prescription); consider condom use if patient has not had 3 months of folate supplementation.
2. Menstrual calendar, cycle beads.
3. Timed coitus every other day at least 3 times starting 2-3 days prior to ovulation. Ovulation may be calculated using prior cycle lengths, cycle beads or urine ovulation detection tests.
4. Nutritional counseling and recommend weight loss if patient overweight.
5. Zika virus education and prevention strategies
- Avoid traveling to impacted areas
- Avoiding mosquito bites if traveling to impacted areas
- Using condoms to prevent transmission of virus
- Avoiding pregnancy if infected or partner infected
1)Risk to unborn fetus
REFERtoMD/ER:
Based on clinical findings or client request.
REFERENCES:
1. Centers for Disease Control and Prevention (CDC). Providing Quality Family
Planning Services, 2014. MMWR: 59(RR-4):1-86.
2. Centers for Disease Control and Prevention (CDC). Zika Virus Homepage-
Reviewed/Revised 2017