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Seminar on infertility
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infertility 2

  2. 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. 3. DEFINITION  Infertility is defined as a failure to conceive within one or more years of regular unprotected intercourse. Annamma Jacob
  4. 4. ANATOMY & PHYSIOLOGY FEMALE REPRODUTIVE SYSTEM Female reproductive system includes - Uterus Fallopian tube Vagina Ovary
  5. 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. 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. 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. 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. 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. 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. 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. 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. 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
  14. 14.  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
  15. 15. 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
  16. 16.  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
  17. 17.  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
  18. 18. 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.
  19. 19. EXTERNAL GENITAL IA  Penis  Scrotum  Testes INTERAL GENITALORGENS  The vas deferens or ducts deferens  The seminal vesicle  The ejaculatory duct  The prostate  The Urethra
  20. 20. 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
  21. 21.  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.
  22. 22. 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.
  23. 23.  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.
  24. 24. 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.
  25. 25. 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.
  26. 26.  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
  27. 27. 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
  28. 28.  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
  29. 29. 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.
  30. 30. 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
  31. 31.  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
  32. 32.  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
  34. 34. STRUCTURE OF SPERM The spermatozoon has a head neck a middle piece and tail-  Head  Neck  Middle Piece  Tail
  35. 35.  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
  36. 36. TYPES OF INFERTILITY PRIMARY INFERTILITY  Primary infertility denotes couples who have never been able to conceive.
  37. 37. 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.
  38. 38.  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
  39. 39.  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
  40. 40.  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
  41. 41.  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.
  42. 42. 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
  43. 43. 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
  44. 44. 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
  45. 45. Endometritis Congenital malformation Cervical factors- Chronic cervicitis Congenital elongation of cervix Second degree uterine prolapse Acute retroversion of uterus. Vaginal Factors Atresia Narrow introitus
  46. 46. 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
  47. 47. 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.
  48. 48.  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.
  49. 49. 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
  50. 50. 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.
  51. 51. 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
  52. 52. 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.
  53. 53.  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
  54. 54.  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
  55. 55. 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
  56. 56. Varicocelectomy SURGICAL MANAGEMENT FOR MALE
  57. 57. Microsurgical reconstruction Vasectomy Reversal
  58. 58. 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
  59. 59.  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.
  61. 61. MYOMECTOMY
  62. 62. SALPINGOSTOMY  This is a surgical procedure for correction of fallopian tube.  This is done to create a new opening when fallopian tube is blocked
  63. 63.  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.
  64. 64. DIFFERENT TECHNIQUES OF ART  In vitro Fertilization and embryo transfer  Gamete intrafallopian transfer  Zygote intrafallopion transfer  Intrauterine insemination  Intracytoplasmic sperm injection
  65. 65. 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.
  66. 66. GAMATE INTRA FALLOPIAN TRANSFER  In this procedure both sperm and unfertilized ovum are transferred into the fallopian tube by using laparoscope for fertilization.
  67. 67.  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.
  68. 68. 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
  69. 69. INTRACYTOPLASMIC SPERM INJECTION  In this procedure single sperm is carefully inserted into the centre of an egg by using a micro needle.
  70. 70. 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.
  71. 71. 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.
  72. 72.  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
  73. 73. HEALTH EDUCATION  Maintain a normal body weight  Exercise  Never have unprotected sex  Do not smoke  Anxiety and depression  Financial aspect
  74. 74.  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
  75. 75. 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