Subfertility
Infertility-or the inability to conceive a child or sustain a pregnancy to childbirth.
Affects 10 to 15%
Pregnancy has not occurred after at least 1 year of engaging in unprotected coitus
Primary infertility- no previous conception
Secondary infertility-had a previous viable pregnancy but the couple is unable to conceive at present
Nursing process:
Assessment- most important
nurse must focus on good communication
nursing diagnosis
Planning
goals
Implementation
counseling
Evaluation
Sterility-the inability to conceive because of a known condition.
Average length of time to conceive:
4 times per week
50% of couples it takes 6 months
after 12 months 85% of couples will conceive
these periods are longer if sexual relations are less frequent
Couples that engage in daily coitus may have more difficulty because this can lower the man’s spermatozoa count to a level below optimal fertility.
Chance of infertility increases with age, due to a gradual decline in fertility
Women who defer pregnancy until their late thirties may have more difficulty conceiving
Women on Depo-Provera or Norplant may not conceive for 2 to 12 months
Oral contraceptives-when menses resumes
Factors that lead to infertility:
Disturbance in spermatogenesis-production of sperm cells.
Sperm count-number of sperm in a single ejaculation or milliliter of semen.
20 million per milliliter or 50 million per ejaculation
At least 60% of sperm are motile and normal
Male Infertility
Conditions that affect sperm count:
elevated body temperature
chronic infections
working at desk jobs
driving a great deal every day
frequent use of hot tubs or saunas
jockey shorts
Congenital abnormalities
cryptorchidism-undescended testes
Varicocele-varicosity of the spermatic vein
increases temperature within the testes
Trauma to testes
Surgery on or near testes
Endocrine imbalances (thyroid, pancreas and pituitary glands
Drug or excessive alcohol use
Environmental factors (x-rays, radioactive substances)
Obstruction in the seminiferous tubules, ducts, or vessels preventing movement of sperm
Diseases:
Mumps orchitis- testicular inflammation and scarring due to the mumps virus
Epididymitis-inflammation of epididymis
Gonorrhea
Urethral infections and adhesions
Qualitative or quantitative changes in seminal fluid preventing sperm motility
Development of autoimmunity that immobilizes sperm
Vasectomies (may form antibodies that immobilize there own sperm
Hypertrophy of the prostate ( age 50)
Anomalies of the penis:
Hypospadias-urethral opening ventral surface of penis
Epispadias-opening on dorsal surface
Extreme obesity
Problems in ejaculation or deposition
Preventing sperm from being placed close enough to the cervix to allow for penetration and fertilization
Erectile dysfunction
Female Infertility
Anovulation-faulty or inadequate production of ova
Most common cause of infertility
Genetic abnormality (Turner’s syndrome)
Hormonal imbalance
Ovarian tumors
Chronic or excessive exposure to x-rays or radioactive substances
General ill health
Poor diet
Stress
Decreased body weight or body/fat ratio of less than 10%
Ovulation patterns vary, some women may ovulate only a few times a year.
Ova discharged from the right ovary may favor fertilization more than the left side.
Tubal Transport Problems:
Usually occurs because of scarring.
PID-Pelvic inflammatory disease-infection of the uterus, fallopian tubes, ovaries and supporting structures
Chlamydia and gonorrhea most frequently
Rate 25/100 (highest in teenagers)
Eschericbiacoli and Streptococcus
IUDs
Uterine Problems:
Tumors
Congenitally deformed uterine cavity
Use of DES
Poor secretion of estrogen or progesterone
Endometriosis-implantation of uterine endometrium, or nodules, that spread from interior of the uterus to locations outside the uterus.
Occurs in 25% of women
Most common sites-Douglas’s cul-de-sac, ovaries, uterine ligaments and outer surface of the uterus and bowel.
Regurgitation through fallopian tubes at the time of menstruation. Viable particles of endometrium begin to proliferate and grow at the new sites, impeding fertility.
Tubal obstruction may result or adhesions
Cervical Problems:
Cervical mucus may be too thick
Cervical erosion
Vaginal Problems:
Infection of vagina may cause the pH of vaginal secretions to acidic
Unexplained infertility:
No known cause
Alternative solutions-adopt, continue trying, agree to a child free life
Fertility Assessment
History and physical assessment:
Thorough
Infertility not always the females problem
Fertility Testing:
Semen analysis:
2-4 days abstinence
2.5 to 5 ml of semen
examined within 1 hour under microscope
should contain 20 million at least (50-200 is normal)
Sperm penetration assay and antisperm antibody testing:
causes agglutination
can exist in women and sperm can not travel to fallopian tubes
vasectomies or obstructions in men cause sperm not to be mobile
test for antibodies if they are present
may use in vitro fertilization methods
Ovulation determination by BBT:
one of the first tests for women
tests for ovulation
temp increase of 0.4 to 1 degree when progesterone is released following ovulation
slight dip 0.5 then normal for 3-4 days may last 10 days.
Female Infertility
Test strip:
kits that test for the upsurge of LH that occur before ovulation
dips in midmorning urine (color change)
marks point just before ovulation
Cervical mucus assessment:
height of estrogen stimulation, copious, thin, low viscosity and cellularity
fern test-mucus placed on a glass slide and allowed to dry
due to crystalization of NaCl on fibers
spinnbarkeit test -high estrogen secretion
mucus is thin, watery and stretches to long strands
midpoint of menstrual cycle
test between thumb and finger or slides
Postcoital test:
ovulation detection and semen analysis
predict ovulation by BBT then have coitus, go to MD office within 2 to 8 hours, specimen is removed and examined
Test shows presence of sperm and how they interact with vaginal or cervical environment.
Ultrasonography and x-ray imaging
sonohysterography-inspects the uterus
uterus is filled with saline through cervix
looking for myoma or septal deviations
hysterosalpingography:radiologic exam of fallopian tubes
radiopaque medium introduced into the
cervix under pressure causing distention
this outlines the uterus and tubes
Surgical Evaluation
Uterine Endometrial Biopsy:
tests for ovulation or endometrial problems
biopsy done 2-3 days before menses
Hysteroscopy:
visual inspection of the uterus through insertion of a hysteroscope through the cervix
Laparoscopy:
small incision in the abdomen under the umbilicus
examines the position and state of the fallopian tubes and ovaries
follicular phase of menstrual cycle under general anesthesia
CO2 in abdomen
Infertility Management
Correction of underlying problems:
increase sperm count
Clomid
reduce presence of infection
trichomoniasis, moniliasis
hormone therapy
Clomid, Pergonal = multiple birth
estrogen Premarin, progerterone
surgery- tumors
Assisted Reproductive Techniques
Artificial insemination:
instillation of sperm into the female reproductive tract
husband or donor sperm
one day after ovulation seminal fluid delivered using a cervical cap or diaphragm
may take 6 months to conceive
Invitro Fertilization and embryo transfer:
removing one or more mature oocytes from the ovary by laparoscopy and fertilizing them in a lab with sperm
ET-insertion of lab grown fertilized ovum into the uterus 40 hours after fertilization.
They must implant and grow
$10,000 a cycle
GIFT-Gamete Intrafallpoian Transfer:
ova and sperm are instilled via laparoscope into the open end of a patent fallopian tube
may use ultrasound to guide the procedure
ZIFT-Zygote Intrafallopian Transfer
oocyte retrieval by transvaginal ultrasound-guided aspiration, followed by culture and insemination of oocytes in the lab
in 24 hours the fertilized eggs are transferred into the fallopian tube
fertilization takes place outside the body
Serrogate Embryo Transfer:
for women who do not ovulate
donors ovum removed
Oocyte is fertilized by husband or donor sperm and placed in woman’s uterus by ET or GIFT
Alternatives To Children
Surrogate mother:
woman who agrees to carry a pregnancy to term for an infertile couple
legal and ethical issues
Adoption:
there are fewer children available
Childfree living:
decide that the emotional and financial cost is not worth it
two careers, travel, hobbies, education
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