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Infertility��Lecture 17

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Objectives

Discuss the causes of infertility, and abnormalities associated with assisted pregnancies.
Define infertility.
Identify the incidence rate of infertility.
Distinguish between the main categories of infertility.
Define the two types of infertility.
Identify the causes of male infertility.

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Objectives

Identify the causes of female infertility.
Discuss the medical management of each type of infertility.
Identify the components of managing infertility at the initial evaluation /counseling /referral.
Identify the complications of assisted conception techniques.
Recognize the management of pregnancy after infertility.
Identify the ethical issues associated with infertility.
Identify the role of the midwife during infertility RX.

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Definitions

Infertility:

failure to conceive after regular unprotected sexual intercourse for 2 years in the absence of known reproductive pathology

Subfertility:

Inability to conceive after 1 year

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Incidence

1 in 7 in the UK
85 % conceive in the 1^st year
95% conceive in the 2^nd year
Factors responsible to infertility: incidence

30 % in men
40 % in women
39 % of cases: with both partners
30% not explained

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Types of infertility

Primary: no prior conception

Secondary : there has been a previous conception

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Causes of male infertility

Defective spermatogenesis

Endocrine disorders

Dysfunction- hypothalamus, pituitary, adrenals, thyroid
Systematic disease: DM, celiac disease, renal failure

Testicular disorders

Trauma
Environmental- congenital, occupational, acquired
Cancer treatment

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Causes of male infertility

Defective transport

Obstruction or absence of seminal ducts
Impaired secretions from prostate or seminal vesicle

Ineffective delivery

Psychosexual problems (impotence)
Drug induced (ejaculatory dysfunction)
Physical disability or anomalies

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Causes of female infertility

Defective ovulation

Endocrine disorders

Dysfunction- hypothalamus, pituitary, adrenals, thyroid
Systematic disease: DM, celiac disease, renal failure

Physical disorders

Obesity, low BMI

Ovarian disorders

Hormonal, polycystic ovarian disease, ovarian endometriosis

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Causes of female infertility

Defective transport

Oocyte

Tubal obstruction- previous surgery, fimbrial adhesions, endometriosis, infection

Sperm

Hostile mucus
Antisperm antibodies in mucus
Psychosexual problems (vaginismus)

Defective implantation

Hormonal imbalance, congenital anomalies, fibroids or infection

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Initial management of the infertile couple

Primary care:

preliminary investigation and
referral to specialist

Early referral: if

Female is over 38 yrs
History of infertility for 3 yrs
Have indicative tubal disorder
Have indicative Ovulation disorder
Male has abnormal semen analysis

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Initial management of the infertile couple

Aim of investigations

Achieving an accurate diagnosis and definition of any cause
Accurate estimation of the chance of conceiving with or without treatment
Full appraisal of treatment options
Providing information, counseling and support to help the couple to cope with the stress

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Initial management of the infertile couple

Both partners are involved in the management
Provide written material
Rubella titer for female
Drug history for both
Advice regarding life style (smoking, alcohol, wt control)

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Initial management of the infertile couple

Intercourse every 2-3 days
Semen analysis for male
Regular menstruation: Serum progesterone level for female to confirm ovulation
Irregular menstruation: progesterone and gonadotrophin levels

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Initial management of the infertile couple

Important predictors for success:

Female age
Duration of infertility
Previous pregnancy history
Quality of the sperm

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Normal values for Semen analysis

Volume: > 2-5 ml
Sperm concentration: > 20 million/ml
Motility >50 % progressive motility
Morphology >30% normal forms
White blood cells <1million /ml

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Assisted conception techniques

Aim: to promote the chances of fertilization and subsequent pregnancy by bringing the sperm and egg close to each other
Types:

Ovulation induction
Intrauterine insemination (IUI)
In Vitro fertilization/embryo transfer (IVF/ET)
Intra-cyto-plasmic sperm injection
Gamete intra-fallopian transfer and Zygote intra-fallopian transfer

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1.Ovulation induction

When to commenced:

Adequate sperm count
Tubal patency

Classifications of ovulation disorders:

Group I: hypothalamic pituitary failure
Group II: hypothalamic pituitary dysfunction
Group III: ovarian failure

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1.Ovulation induction:� Group II treatment:

Clomifene citrate and tamoxifen: ovulation induction

Anti-estrogenes: blocking estrogen receptors in the hypothalamus
Inducing

–ve feedback
Gonadotrophin secretion
FSH stimulation

Side effects:

multiple pregnancy,
ovarian hyper stimulation,
Abdominal discomfort
Hot flushes

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1.Ovulation induction:� Group II treatment:

Treatment : up to 12 months
Women education about the risks
Need ultrasound monitoring for the 1^st cycle

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1.Ovulation induction:�clomifene-resistant polycystic ovarian syndrome

Treated with gonadotrophins
Need U/S monitoring throughout the treatment
Measure the follicle size and number to prevent multiple pregnancy

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Ovulation induction:�hyper-prolactin-emia

Treated with dopamine agonists

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2. Intrauterine insemination (IUI)

Needed for the following problems:

Hostile cervical mucus
Antisperm antibodies
Male fertility problems (low sperm count, premature ejaculation)
Unexplained infertility

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2. Intrauterine insemination (IUI)

To increase the success:

Monitor ovulation
Induce ovulation
Sperm prepared

1^st 4 attempts have more success rates

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IUI

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3. In Vitro fertilization/embryo transfer (IVF/ET)

Fertilization occur out side the body
Indication:

Uterine tube occlusion
Endometriosis
Cervical mucus problems
Male factors are the main problem
Unexplained infertility
Unsuccessful less invasive methods
Detect sperm abnormalities and its fertilization ability

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3. In Vitro fertilization/embryo transfer (IVF/ET)

Stimulate the ovary to produce more than one egg with pituitary desensitization
Control oocyte release: by controlling LH by GnRH agonists and antagonists
Monitoring the ovaries is needed

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3. In Vitro fertilization/embryo transfer (IVF/ET)

HCG injection before egg collection (34-38 hrs)
oocyte retrieval transvaginally
Put mature oocyes and sperms together
Incubate them
4 - 8 cell stage will be transferred (2-3 days)
Age <40 yrs: 2 embryos will be transferred
Age >40 yrs: 3 embryos will be transferred
Remaining embryos may be frozen

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IVF

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5. Intra-cyto-plasmic sperm injection (ICSI)

Developed in 1992
Used When

sperm quality is poor
Azoospermic men: obtained sperm surgically)

Involves the injection of a single sperm into the cytoplasm of an egg

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Intra-cyto-plasmic sperm injection

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6. Gamete intra-fallopian transfer and Zygote intra-fallopian transfer

Little clinical advantage
Not recommended

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Gamete intra-fallopian transfer

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Zygote intra-fallopian transfer

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Complications of assisted conception techniques

Ovarian hyper-stimulation syndrome
Ectopic pregnancy
Multiple pregnancy
Intra-cyto-plasmic sperm injection and IVF

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1. Ovarian hyper-stimulation syndrome

Life-threatening
Incidence:

0.6 – 10 % of IVF
0.5 – 2 % in sever forms

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1. Ovarian hyper-stimulation syndrome

Risk factors

Poly-cystic ovarian syndrome
Young age
Lean physics
HCG administration
Multiple pregnancy

Treatment:

In hospital
Multidisciplinary team

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2. Ectopic pregnancy

4-5 %
Detected early because of U/S

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3. Multiple - pregnancy

Increase risk of preterm labor
Higher order multiple (3 or more)

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4. Intra-cyto-plasmic sperm injection and IVF

Major birth defect risks (twice risk)
Chromosomal abnormalities increase with low sperm count

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Issues of infertility

Sperm and egg donation
Surrogacy
Psychosocial and psychological aspects of infertility
Psychosexual aspects of infertility

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Psychosocial and psychological aspects of infertility

Feelings:

Guilt
Anger
Depression
Anxiety
Inadequacy
Greif
Loss of control
Low self-esteem

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Psychosocial and psychological aspects of infertility

Women reported to have more significantly higher levels of depressive symptoms
Most upsetting experience in their lives
Women receive the bulk of invasive procedures
Women appear to negotiate the transition to childless lifestyle more difficult than men
Positive effect: couple more close to each others

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Issues for the counselors

The central focus is the couples inability to have children
Couple’s desire to have children
Repeated unsuccessful therapies cause more stress
Sharing sexual behavior information
Deciding when to stop is not an easy decision

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ethical issues associated with infertility

Resourcing and financial issues
Welfare of the child
Parents age
Donors
Right of the child to know the biological parents
surrogacy

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role of the midwife during infertility RX

Should be aware of the types and implications of tx
Able to provide empathetic and sensitive care for couple’s needs
Support couple throughout pregnancy and postnatal (difficult parenthood)

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Family planning��Lecture 18

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Family Planning

Is related to all decisions couples make about having children, and how they are spaced.
Contraception is the voluntary prevention of pregnancy.

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Family planning�

Contraceptive failure rate: is referred to the percentage of contraceptive users to experience an accidental pregnancy during the first year, even when they are using the method consistently and correctly
Failure rates decrease over time
Factors affecting method effectiveness are frequency of intercourse, motivation to prevent pregnancy, understanding of how to use the method, likelihood of pregnancy for the individual woman.

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Family planning�

When teaching about family planning you should pay attention on teaching the couples:

How to use the F.P method
Give information about emergency contraception
Information about decreasing the risk of unintended pregnancy.

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Assessment

History ( physical, obstetrical, contraceptive use)
Physical examination
Laboratory tests
Note their verbal and non-verbal responses

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Assessment and Nursing Diagnoses

Assess the woman’s and her husband’s knowledge about contraception
Assess their commitment to any particular method
Assess the frequency of coitus
The woman’s willingness to touch her genitalia
Assess their preference to any particular method

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Nursing Diagnoses

Fear related to

Contraceptive method side effects

Risk for decisional conflict

Contraceptive alternatives
Husband’s willingness to agree on the method

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Nursing Diagnoses

Risk for altered sexuality pattern related to fear of pregnancy
Risk for infection related to

Use of contraceptive method
Broken skin secondary to surgery, IUD insertion

Spiritual distress related to discrepancy between religious or cultural beliefs and the use of the contraceptive method

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Expected outcome of care

Planning should be between the woman, her partner, primary health nurse and specialized health care provider
The outcomes should be measured in client-centered terms and may include that the woman and her partner will do the followings

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Expected outcome of care

Verbalize understanding about contraceptive methods
Verbalize understanding to all information necessary to give informed consent
State comfort and satisfaction of the used method
Use the method consistently and accurately
Achieve pregnancy when planned

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Intervention�

Build trust relationship and maintain privacy
Alternate myths with facts, clarify information and fill in gaps of knowledge

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Methods for family planning

Hormonal
Non-hormonal

Natural
Mechanical

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Non-nhormonal- Natural methods

Coitus interruptus (withdrawal): the male withdrawing the penis from the woman's vagina before he ejaculates. Its act by prevent the meeting of sperm with the ovum .�
Periodic abstinence : avoiding intercourse during the fertile periods

Fertility awareness: combination of the charting signs and symptoms of the menstrual period with abstinence

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Fertility Awareness Method: Knowledge of menstrual cycle

Ovum can be fertilized no later than 16-24 hours after ovulation.
Sperms stay motile in female genitalia up tp 60 hours after coitus, However their ability to fertilize lasts no longer than 24-48 hours.
Pregnancy is unlikely to occur if the couple abstains from intercourse for 3-4 days before and after ovulation.

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Calendar rhythm method

Calendar rhythm method :

calculating the time at which the ovulation is likely o occur based on the lengths of the previous menstrual cycle.

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Detection of ovulation

There are some methods the woman can detect the time of ovulation :
Sympto-thermal method: using a combination of methods.

Cervical mucus method: recognizing the changes in cervical mucus.
Temperature method :recording the rise in basal body temperature as a result of the thermogenic effect of progesterone. �

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Disadvantages

Exact time for ovulation can not be determined
Couples may find it difficult to abstain from intercourse for 16 days a month
Women with irregular menses have greater risks of failure

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Non Hormonal Methods

Barriers Methods- mechanical methods

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Non-Hormonal Methods

IUD
Condoms
Spermicides
Diaphragm
Cervical Cap

Tubal Ligation
Vasectomy
Fertility Awareness Method

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IUD

Act as a barrier method
Efficacy : 99.2-99.4%
Advantages:

lasts for 10 years
Private
No hormonal side effects

Disadvantages/Side effects:

1^st 6 months heavier, crampier menses
Spotting

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Definition:

It is a type of modern uterine contraceptives, it is a plastic body not more than 3 cm long, and the most significant types used in Jordan is T-shaped material called (T-Copper).

Copper wires surrounding its body and its terminals covered by small copper pieces to increase its effectiveness.

Its lower part connected with a Nylon thread to enable the doctor pulling it when the client tends to remove it. It is inserted in client’s uterus.

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(IUD) prevents conception by its effect on sperms and prevention the meeting with ovum and making mechanical, not microbial and not diseasing inflammation by irritating the walls of the uterus to let it unsuitable environment for conception and copper increases its work effectiveness.

The best time for inserting IUD is during menstrual period between the 3^rd and 5^th day of menses or after delivery in the 6th week. Also it is preferred to be inserted immediately after abortion if abortion was in the 1st trimester and there are no pelvic infections.

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Advantages . . .

High effectiveness percent (99%).
Provide protection for 10 years (copper type 380).
Ability conception returns back immediately after IUD removal.
For all ages.

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Side effects . . .

Some women could complain of lower abdominal pain during and after insertion.
May increasing in menses blood quantity or number of days and pain before or during menstrual period during the first 3 or 6 months of insertion, but these side effects gradually disappear.

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Special tips . . .

Client must visit doctor to do the regular tests according to specified dates.
Client must revise the clinic if there are any questions or abnormal complains.

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Condoms

Important messages regarding condoms

Natural condoms are less effective at preventing disease ( if allergic to latex, a natural condom should be placed under a latex condom)
Nonoxynol-9 spermicidal may increase vaginal irritation thereby increasing the risk of STI’s and HIV
Use only once
If it tears or falls off, the woman should insert a spermicidal immediately and consider emergency contraceptive

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Spermicides

Work by killing sperm
71-85% effective
May cause allergy or irritation

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Tubal Ligation

Most widely used method
Very effective (99.9%). Not easily reversed

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Vasectomy

Very effective (99.9%), not easily reversed
Two methods, both outpatient procedures:

Surgical:

Involves cutting and cautery

Non surgical: FDA approved Vasclip

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0ral Contraeptive (OCs)

OCs: is a hormonal method of contraception that is administered orally .

*There is two type of OCs:

Combined estrogen _ progestrin oral contraceptive.
Progesrtin _only contraceptive.

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Combination Hormonal Methods (estrogen and progestin)

Birth control pills
The Ortho Evra patch

(All of these methods are very similar in how they work, the difference is how they are delivered)

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Combination Hormonal Methods (estrogen and progestin) How do they work?

The hormones prevent the ovary from releasing an ova
They also thicken a women’s cervical mucus which makes it difficult for sperm to penetrate

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Combined estrogen _ progestine method

There are two types:

1-Monophasic pills (fixed dosage of estrogen and progestrin .
2-phasic pills (biphasic, triphasic, multiphasic)

MODE OF ACTION: regular ingestion of combined OCs suppress the action of the hypothalamus and anterior pituitary ; cause in appropriate secretion of FSH, LH. So follicles do not mature and ovulation is inhibited (estrogen).

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The cervical mucus remain thick, not suitable for sperm penetration, no full development of the endometrium (progestrine).

Direct effect on the endometrium from 1-4 days after the last combined OCs is taken ,indometrium bleed as result of hormone with drawal , less profuse than that of normal menstruation last for 2-3 days some women have no bleeding at all.

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WHEN WE USE (OCs) ?

on one of the first 7days of menstrual cycle
After 3-6weeks of childbirth ,with no breast feeding .
After 3weeks of abortion .
The combined (OCs) should not be used with breast feeding untill 6^th month .
1 pill is taken daily (for 3_4weeks).
Over all the effectiveness rate is almost 100%, all failure are caused by omission of one or more pills, (5%) failure rate .
Effect of pregnancy. explain .

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ADVATEGES:

Decrease menstrual blood loss, decrease iron- deficiency anemia, protect from the incidence of breast and ovary cancer, decrease risk of ectopic pregnancy, it is a safe option for older, non- smoking women .

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Disadvantages of combined (COs)

Missing of pills .
Affect of milk production .
Some women may have decrease of sexual enjoyment.
Not protect from sexual transmitted disease and (AIDS).

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Side Effect

Side effect of progestin excess : increase of appetite , tired ,depression ,breast tenderness,vaginal yeast infection .
Progestrin dificiency : late spotting (15-21) days, heavy flow with clots , decrease breast size , the common one is bleeding irregularity

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Prostrine –Only Contraceptive

It is pills contains progestrine hormones only ,it cause thinning of endometrium ,thickening and decrease the amount of cervical mucus .

less effective than combined OCs .
Because of low dose of progestrin the pills must be taken at the same time every day .
This type taken every day even through the menstrual flow , it doesn’t interfere with milk production ,it may be taken during breast feeding .
It has advantages for the women who can’t take an estrogen based pills because of the danger of thrombophlebitis.

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WHO Recommends

Do Not provide combined (OCs): to women with history of

thromboembolic disorder ,
cerebrovascular accident ,
coronary artery disease ,
breast cancer ,
impaired liver function ,
lactation
less than 6 weeks post partum ,
over 35 years old
,hypertention ,
diabetesmellitus.

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Danger Signs

A: Abdominal pain, severe
C: Chest pain, SOB
H: Headaches, severe or changes is frequency or severity
E: Eye problems: blurred, double or loss of vision
S: Severe arm or leg pain

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Side Effects

Menstrual irregularities
Spotting
Headaches
Breast tenderness
Nausea
Weight gain due to increased appetite or fluid retention
Mood changes, lowered libido

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