Infertility

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. 2. 3. 4.

Anovulation Problems of ova transport Uterine factors 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 incubatorlike 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