infertility in detailed

1. SEMINAR ON INFERTILITY
PRESENTED BY-
SHREYA YADAV

2. INTRODUCTION
 Infertility is typically defined as the inability to become
pregnant after one year of sexual intercourse without
contraception .
 For women over age 35 , this condition is diagnosed after 6
month of an inability to conceive. In a life time 10-15% of couples
will experience infertility.
 In about 45% of the cases there is a male origin for the
infertility.

3. DEFINITION
 Infertility is defined as a failure to conceive
within one or more years of regular unprotected
intercourse.
Annamma Jacob

4. ANATOMY & PHYSIOLOGY
FEMALE REPRODUTIVE SYSTEM
Female reproductive
system includes -
Uterus
Fallopian tube
Vagina
Ovary

5. UTERUS
 The uterus is a hollow
muscular organ situated
in the pelvic between
the bladder in front and
rectum behind.
 The uterus is the
pathway for sperm
deposited in the vagina
to reach the uterine
tube.

6.  It is also site of implantation of a fertilised ovum
development of foetus during pregnancy &
labour.
 When implantation does not occur the wall of the
uterus is the source of menstrual flow.

7. ANATOMY OF UTERUS
 It is a single hollow muscular pear-shaped structure
between the urinary bladder & rectum.
 Length- 7-8
 Width- 5-7
 Thickness -2-3
 Weight -30-40
PARTS OF UTERUS
 Fundus
 Body
 Cervix

8. LAYERS OF UTERUS
 Perimetrium- It is outer thin
covering of uterine wall.
 It is a double serous membranes an
extension to peritoneum.
 Myometrium- It is middle thick layer
of smooth muscle fibres which
contracted strongly during delivery
of delivery.
 Endometrium – It is inner layer that
contains glands and many blood
vessels.

9.  It provide site for implantation.
 It provide platform for development of foetus.
 Cervix part of uterus form the birth canal to facilitate
parturition.
 After puberty undergoes cyclical changes known as
menstrual cycle.
FUNCTIONS OF UTERUS

10. FALLOPIAN TUBE
 The fallopian tube is also called ‘uterine tube’.
 The uterine tube are paired structures measuring about 10-12cm
long.
 It is situated in medial three fourth of upper free margin of the
broad ligaments.
 It is responsible for fertilization.
Parts of the Fallopian tube
 The Infundibulum
 Ampulla
 The Isthmus

11.  Mucosa- It consist of epithelium & lamina propria . This is
secrete a fluid that provides nutrition for ovum.
 Muscularis- It has on inner thick circular ring of smooth
muscle. It helps to move the ovum towards uterus.
 Serosa- It is outer most layer of uterine tube is a serous
membrane.
LAYER OF THE FALLOPIAN TUBE

12.  They carry oocytes from the ovaries to the site of
fertilization.
 They carry sperms from the uterus to the site of
fertilization.
 The uterine tube also conveys the dividing zygote to
the uterine cavity.
FUNCTIONS OF FALLOPIAN TUBE

13.  Vagina is a fibro muscular canal extending from the vulva to
uterus.
 Vagina lies between the urethra and bladder, in front and the
rectum and anal canal behind.
 ANATOMY
 Length –Anterior wall is 8cm
 Posterior wall is 10cm.
 Diameter- Upper end is wider 5cm
 Lower end is narrow2.5cm
 Shape of lumen – H shaped
VAGINA

15.  It from an important passage from uterus to exterior that help
in birth of baby.
 Flow of menstrual blood exterior.
 It acts as receptacle for the male capulatory organ, penis for
deposition of sperm.
Blood Supply- Vagina is supplied by uterine artery, vaginal artery
and middle rectum artery.
Nerve supply-Sympathetic and parasympathetic nerves.
FUNCTION OF VAGINA

16. OVARIES
 The ovaries are the female gonads . They are two in number,
situated one each side of the uterus in a fossa behind the broad
ligament.
 The ovaries are situated on the lateral wall of the pelvis.
Shape and size
 Each ovary is ovoid in shape
 3cm-long
 1.5cm –wide
 1cm -thickness

17.  Ovarian function – Ovaries are the store house of female gametes
or ova.
 There are about 1.2 million primordial follicles at puberty.
 Ovary secretes two steroid hormones, estrogens and
progesterone.
 Synthesis and secretion of ovarian hormone is under control of
pituitary gonadotropins FSH and LH
Blood supply- the ovarian artery a branch of abdominal aorta
supplies the ovary
Nerves- Sympathetic and parasympathetic nerves.
FUNCTION OF OVERIES

18.  The gonadotropin releasing hormone (GnRH) from hypothalamus
stimulates the release of FSH from anterior pituitary.
 FSH stimulates the development of the granfian follicle which
secretes estrogens. Estrogens is responsible for the proliferative
changes in the endometrium .when estrogens level increase ,it
inhibit FSH secretion.
 The rapid rise of estrogens occurs about 24 hours before ovulations
.after which it drops.
 Corpus luteum secretes progesterone as well as estrogens, the
increased level of progesterone and estrogens inhibit LH and FSH
secretions.
 Regression of corpus luteum drops the level of estrogens and
progesterone causing menstrual bleeding.
HORMONES

20. MALE REPRODUCTIVE SYSTEM
 In males the reproductive system is closely related to the urinary
system .
 The urethra is shared by the urinary and genital system.
 The male reproductive organs include the external and internal
genitalia.

21. EXTERNAL GENITAL IA
 Penis
 Scrotum
 Testes
INTERAL GENITALORGENS
 The vas deferens or
ducts deferens
 The seminal vesicle
 The ejaculatory duct
 The prostate
 The Urethra

22. PENIS
 It is the male organ to excrete urine out side the body and to
release the sperms in female genital tract. It is made up of two
parts namely.
 Root of penis
 Body of penis
ROOT OF PENIS
 It is situated in superficial perineal
pouch and consists of :-
-Two crura
-Bulb of penis

23.  BODY OF PENIS
 It is mad up of a pair of corpora cavernous and a single
corpus spongiosum.
FUNCTION OF PENIS
 It is a passage for urine to exterior.
 It is responsible for ejaculation of semen deposition in
vagina.
Arterial supply- Arterial blood is supplied by deep, dorsal
arteries of penis.
Venous supply- prostatic venous plexus.

24. SCROTUM
 The scrotum is a loose cutaneous
fibro muscular sac that is situated
posterior inferior to the penis and
inferior to the pubic symphysis. It is
composed of skin and dartos
muscle.
FUNTION OF SCRTUM
 In hot weather the scrotum relaxes
and allow the testes to hang freely
away from the body.

25.  It help to maintain a stable temperature.
 It is an important function because
spermatogenesis will be impaired by extremes of
heat or cold.
Blood supply- Scrotum is supplied by superficial and
deep external pudendal vessels.
Nerve supply- anterior surface is supplied by L1
segment of spinal cord
The posterior surface is supplied by S3 segment,
through scrotal branches of pudendal nerve.

26. Testes
 Testes is the male gonad . It is homologous with the ovary of
female .
 It is suspended in the scrotum by the spermatic cord.
 Each testis is ovoid in shape.

27. SIZE
 Length-5cm
 Thickness-2.5cm
 Breath-3cm
Weight- 10-15cm
COVERING OF THE TESTES
 Outermost Tunica Virginals
 Middle Tunica albuginea
 Inner Tunica vasculosa
Arterial supply- testicular artery and branch of abdominal artery.
Venous drainage- Testis is drained by pempinifeorm plexus.

28.  Testes produce sperms or spermatozoa sertoli cells in the semini
ferous tubules of testes are responsible for following function.
 Provide nourishment and support to the germ cells.
 Synthesize androgen binding protein that maintain high
testosterone level in testes.
 Thigh junction between sertoil cells provide the blood tests
barrier.
 Testes also produce two hormones testosterone.
 Estrogen :- In very small quantities.
FUNCTION OF TESTES

29. EPIDIDYMIS
 It is a comma shaped body made up of highly coiled
tubes situated along the lateral part of the posterior
border of testes
 Maturation of sperms takes place in the epididymis
It has following parts-
 Head
 Body
 Tail

30.  The ducts deferens is a thick – walled muscular tube
 It is the continuation of the duct of the epididymis ;
 It begins in the tail of the epididymis and ends by joining the
ducts of the seminal vesicle to form the ejaculatory duct.
SEMINAL VESICLES
 The seminal vesicle is a thin-walled, pear shaped structure 3-
5cm long that lies between the fundus of the bladder and the
rectum.
VASDEFERENS OR DUCTUS
DEFERENS

31. EJACULATORY DUCTS
 The ejaculatory ducts are about 2.5cm long. These slender
tube formed by the union of ducts of the seminal vesicle and
the ducts deferens, pass through the prostate and open by
slit-like opening in to the posterior wall of the prostatic
urethra one on each side of the prostatic utericle.

32. PROSTATE GLAND
 This is the largest accessory gland of the male reproductive
system . It is a fibro muscular glandular tissue. Its secretions add
to the volume of semen.
STRUCTURES PASSING THROUGH PROSTATE-
 Prostatic urethra
 Prostatic utericle
 Ejaculatory duct

33.  Arterial supply-
 Inferior vesicle artery
 Middle rectal artery
 Internal Pudendal artery
Venous drainage- it is drained by prostatic venous
plexuses
Lymphatic drainage-
 Internal iliac lymph node
 External iliac lymph node
 Sacral group of lymph node

34.  Spermatogenesis is the process by which the sperms are
formed. Spermatogenesis takes place in the seminiferous
tubules. It begins at puberty and continues throughout adult life
and declines in old age.
 Two types of cells are seen in the seminiferous tubules.
 Leydig cells
 Sertoli cells
SPERMATOGENSIS

35. STEPS OF SPERMATOGENSIS

36. STRUCTURE OF SPERM
The spermatozoon has a
head neck a middle piece
and tail-
 Head
 Neck
 Middle Piece
 Tail

37.  SEMAN OR SEMINAL FLUID
 It is a milky opalescent mucoid fluid which contains
sperms and the secretions of seminal vesicles
prostate Cowper's gland and bulbourethral glands.
 The average volume of semen is 2.5 -3.5 ml per
ejaculation.
 Normal Ph – 7.5
 Each ml of ejaculation contains 60 - 100 million sperms
SEMINAL FLUID

38. TYPES OF INFERTILITY
PRIMARY INFERTILITY
 Primary infertility denotes
couples who have never been
able to conceive.

39. SECONDARY INFERTILITY
 Secondary infertility indicates difficulty conceiving after
already having conceived (either carried the pregnancy to
term or had a miscarriage).
SUBFERTILITY
 Subfertility refers to a state in which a couple has tried
unsuccessfully to have a child for a year or more. The term sub
fertile means less fertile than a regular couple.

40.  Generally world wide it is estimated that one in
seven couples have problem.
 Available data indicate at least 50 million couples
word wide experience infertility.
 According to a systematic analysis of national health
surveys in 2018 approximately 10.5% of women
around the word experienced infertility.
INCIDENCE

41.  Healthy spermatozoa should be deposited high in the vagina at
or near the cervix.
 Spermatozoa should undergo and acquire motility in cervical
canal.
 Motility -spermatozoa should ascend through the cervix into
the uterine cavity and fallopian tube
 Ovulation -ovum should reach the fimbriated end of the tube .
 Patient fallopian tube –Fertilization should occur at the
ampulla of the tube.
 Transportation of fertilization ovum to uterine cavity in 3-4
days the fertilized ovum should reach the uterine cavity for
nidation.
FACTOR REQUIRED FOR FERTILITY
FOR MALE AND FEMALE

42.  Age – The quality and quantity of women eggs begin
decline with increasing age more than 35.
 Smoking-it will damage the cervix fallopian tube
and increase the risk of miscarriage and in male
decrease the motility of sperm
 Body weight-The chances of infertility is increased if a
person is obese .In men sperm count and
testosterone level decrease and in female it will
effect ovulation.
RISK FACTORS

43.  Irregular periods- irregular period are common in
woman who are under wt and over wt which may
lead to infertility.
 Infection- It also cause infertility because in female it
may s damage fallopian tube and in male testes.

44. Defective spermatogenesis - causes of defective infertility
includes-
 Congenital- undescended testes are congenital condition in
which spermatogenesis is depressed.
 Hypospadias- it cause failure to deposit sperm in the vagina.
 Endocrine factor- FSH level is seen raised in idiopathic testicular
failure. Hypoprolectenemia is associated with impotence.
 Gonadotropion Supersession-
 Thermal factor- the scrotal temperature has to be 1-2 degree
farehenite less than body temperature. it is raised in condition
such as vericocele ,hydrocele which leads to infertility.
 Infection
CAUSES OF MALE INFERTILITY

45. Obstruction of the efferent ducts-Efferent duct
may be obstructed by gonococcal or tubulucar infection.
Surgical trauma like vasectomy may lead to obstruction.
Failure to deposit sperm high in the vagina
Erectile dysfunction
Ejaculatory dysfunction such as premature or absence of
ejaculation.
Hypospidiasis
Coital problem
Errors in seminal fluid-
Unusually high or low volume of ejaculate(normal
volume is 2ml or more).
Undue viscosity
Low fructose content

46. Ovarian Factors-
Anovulation or oligo- ovulation
Tubal and peritoneal factor-
Peritubal adhesion
Salpingitis
Polyp with in the lumen
Uterine Factor-
Fibroid
Uterine hyperplasia
CAUSES OF FEMALE INFERTILITY

47. Endometritis
Congenital malformation
Cervical factors-
Chronic cervicitis
Congenital elongation of cervix
Second degree uterine prolapse
Acute retroversion of uterus.
Vaginal Factors
Atresia
Narrow introitus

48. Combined Factors-
Age of wife beyond 35
Inadequate intercourse less than 4-5 wk
Apareunia and dyspareunia
Use of lubricant during intercourse which may be
spermicidal.
Family history

49. DIAGNOSTIC EVALUATION FOR
MALE
 Medical history- past medical and surgical history.
 History regarding family history of infertility
 Ask the pt about social history and occupational hazards
 Physical Examination-examine both testes are present
and their normal size and presence of enlarged
testes(hydrocele )it may leads to abnormal sperm
production.
 Abnormalities of penis like hypospadiasis.

50.  Laboratory test include-
urinanalysis can indicate presence of infection.
 Hormonal tests –evaluate the levels of testosterone and FSH.
 Anti sperm antibodies test- presence of any antibody that may
contribute to infertility.
 Ultrasonography-To detect vericocele or duct obstruction in the
prostate or ejaculatory duct.

51. DIOGNOSTIC EVALUATION FOR
FEMALE
 History-
Pregnancy History-Gravida ,parity ,past pregnancy
complication ,types of contraceptive use.
 Physical Examination – during palpation if there is any mass
present in abdomen it may indicate Fibroid and if tenderness
is present it may suggest PID or ovarian cyst
 Speculum Examination – cervical cancer or abnormal
discharge
 Sonography-find out ovarian cyst ,fibroid sizae and sape of
fallopian tube and uterus

52. Serial basal body temperature
 The basal body temperture is a
simple means of determining
whether ovulation has occur or
not. During ovulation females
body temperature increased
0.1-0.2 degree Celsius.

53. MANAGEMENT OF INFERTILITY
 General Instruction-
Body weight –Over wt or
under wt of any partner
should be adequately
dealt with to obtain an
optimal wt

54. Ideal coital frequency- 14 th day of menstrual period is
the period of ovulation in which there is more chance
to conceive so we can advice for frequent coitus that
time.
Smoking and alcohol- Excess smoking or alcohol
consumption to be avoided.

55.  Human chorionic gonadotropin for hypogonadism.
 Dopamine agonist for hyper prolactinemia and altered
testosterone level and to improve libido potency and
fertility.
 Antibiotics for genital tract infection.
 Clomiphene citrate to increase serum levels of LH FSH and
testosterone .
MEDICAL MANAGEMENT FOR MALE

56.  General care-
Reduction of wt in obese
Avoidance of alcohol and smoking
Avoidance of tight and warm garments
Avoidance of medication that may interfere
spermatogenesis such as anticonvulsant
,antidepressant and beta blocker

57. Ovulatory dysfunction-
 Induction of ovulation using drugs such as clomiphene citrate
letrozale, FSH hCG and GNRH.
 Correction of biochemical abnormality met for hyperinsulinemia
dexamethasone for androgen excess, bromoceriptine for
prolactin excess.
 Substitution therapy – Thyroxin for hypothyroidism antidiabetic
drugs for diabetes mellitus.
MEDICAL MANAGEMENT FOR
FEMALE

58. Varicocelectomy
SURGICAL MANAGEMENT FOR MALE

60. Microsurgical reconstruction
Vasectomy Reversal

61. SURGICAL MANAGEMENT FOR
FEMALE
 Laparoscopy- it is used to
examine or operate the
interior part of pelvic cavities in
which one narrow optic fibre is
inserted through an incision.
it includes-
-Ovarian cystectomy-It the
procedure for removal of cyst
from ovary

62.  Hysteroscopy-It is a
procedure in which the
doctor will use a narrow
optic fiber telescope
inserted into the uterus
through cervix to look
and sometimes to
remove adhesion.

63. SALPINGECTOMY

64. MYOMECTOMY

65. SALPINGOSTOMY
 This is a surgical procedure for correction of
fallopian tube.
 This is done to create a new opening when
fallopian tube is blocked

66.  Assisted reproductive technology encompasses all
method used to achieve pregnancy by artificial or partially
artificial means.
 It involves manipulation of gametes and embryos outside
the body for the treatment o f infertility.

67. DIFFERENT TECHNIQUES OF ART
 In vitro Fertilization and embryo transfer
 Gamete intrafallopian transfer
 Zygote intrafallopion transfer
 Intrauterine insemination
 Intracytoplasmic sperm injection

68. IN VITRO FERTILIZATION
 Fertilization of ovum outside
the body is a technique used
when a women has blocked
fallopian tubes or some other
impediment to the union of
sperm and ovum in the
reproductive tract.

69. GAMATE INTRA FALLOPIAN
TRANSFER
 In this procedure both
sperm and unfertilized
ovum are transferred into
the fallopian tube by using
laparoscope for
fertilization.

70.  In ZIFT egg cells are removed from the woman’s ovaries and
fertilized in the laboratory the resulting zygote is placed in the
fallopian tube.

71. INTRAUTERINE INSEMINATION
 Intra uterine insemination involves placing increased
concentration of motile sperm close to the fallopian tube by
passing the cervical canal.
 It may artificial insemination donor(AID) or artificial insemination
husband(AIH)
 Indication-
Cervical stenosis
Hypospiadiasis
Oligospermia
Hostile Cervical mucus
Unexplained infertility

72. INTRACYTOPLASMIC SPERM
INJECTION
 In this procedure single sperm
is carefully inserted into the
centre of an egg by using a
micro needle.

73. COMPLICATION
 Relations problems-Infertility can make relationship
troublesome. it can leads to severe marital discard and
family problems.
 Social stigma-Infertility is associated with social stigma.
Infertile women may have to face severe criticism in some
areas of society, this leads to guilt feeling.

74. NURSING MANAGEMENT
 Improve the general health of the patient.
 Reduce weight if the person is obese.
 Tell the patient to avoid heavy smoking and alcohol.
Advice the patient to avoid tight and warm
undergarment.

75.  Check the body mass index .This should be
between 20-24.
 Advice and teach the couple about the proper
technique of intercourse.
 Tell the couple to have intercourse in mid cycles
this will give result early enough.
 Encourage the patient to take cold scrotal bath at
least twice a day for 5min.
 Advice the patient to take vitamin E Vitamin C B12
and folic acid as they improve spermatogenesis

76. HEALTH EDUCATION
 Maintain a normal body weight
 Exercise
 Never have unprotected sex
 Do not smoke
 Anxiety and depression
 Financial aspect

77.  For most couples a cause for the infertility is found.
Pregnancy occurs with the use of fertility drugs or
corrective surgery in a majority of infertile couples.
Once they are evaluated and treated . Advanced
techniques such as surgery insemination or in vitro
fertilization can help even more couples achieve
pregnancy.
PROGNOSIS

78. Ineffective sexual intercourse related to painful
intercourse as evidence by verbalization.
Fear and anxiety related to infertility treatment as
evidence by facial expression.
Knowledge deficit reated to infertility as evidence by
asking more question.
Disturbed sleeping pattern related to stress as evidence
by sunken eyes.
Nursing diagnosis