In detail infertility for 1st year Msc nursing

1. KRISHNA INSTITUTE OF NURSING
SCIENCES, KARAD.
OBSTETRICS AND
GYAECOLOGICAL NURSING
INFERTILITY
GUIDED BY : DR. JYOTI A.
SALUNKHE
PRESENTED BY: SRUSHTI C.
GHADGE

2. OBJECTIVES:
General objectives:
At the end of the seminar student
will have in-depth knowledge
regarding infertility, its causes and
diagnostic evaluation and its
management.

3. Specific objectives:
At the end of the seminar student will able
to:
Define infertility
Explain the types of infertility
Factors required for fertility in male and
female
Explain the causes of male and female
infertility
Identify diagnostic tests of infertility
Explain the management of male and
female infertility and also the management
of unexplained infertility
Discuss the role of nurse in management
of infertility

4. INTRODUCTION
Infertility primarily refers to the
biological inability of a person to
contribute to conception. Infertility is
the failure of a couple to become
pregnant after one year of regular,
unprotected intercourse. In both men
and women the fertility process is
complex.

5. INTRODUCTION
Infertility affects about 10% of all
couples. Infertility problems are due
to female as well as male infertility or
combine both. . Although testing of
infertility in women, it is equally
important for the male partner to be
tested at the same time.

6. INCIDENCE
Generally, worldwide it is estimated
that one in eight couples have
problems conceiving. Nearly 80% of
couples achieve conception, if they so
desire within 1 year of having regular
intercourse with adequate frequency
(four to five times a week). Another
10% remain infertile by the end of 3rd
year.

7. INCIDENCE
According to the Indian Society of
Assisted Reproduction, infertility
currently affects about 10 to 14
percent of the Indian population, with
higher rates in urban areas where one
out of eight couples is impacted.
Nearly 27.5 million couples actively
trying to conceive suffer from
infertility in India.

8. DEFINITION
Infertility is defined as a failure to
conceive within one or more years of
regular unprotected intercourse.
Subfertility refers to a state in
which a couple has tried
unsuccessfully to have a child for a
year or more. The term subfertile
means less fertile than a regular
couple.

9. TYPE OF INFERTILITY
Primary infertility denotes
couples who have never been able to
conceive.

10. TYPE OF INFERTILITY
Secondary infertility indicates
difficulty conceiving after already
having conceived (either carried
pregnancy to term or had a
miscarriage).

11. FACTORS REQUIRED FOR
FERTILITY (MALE AND
FEMALE)
Healthy spermatozoa should be
deposited high in the vagina at or
near the cervix.
Capacitation and acrosome
reaction; spermatozoa should undergo
changes and acquire motility in
cervical canal.
Motility: spermatozoa should
ascend through the cervix into the
uterine cavity and fallopian tube.

12. FACTORS REQUIRED FOR
FERTILITY (MALE AND
FEMALE
Ovulation: Ovum should reach the
fimbriated end of the tube.
Patent fallopian tube: Fertilization
should occur at the ampulla of the
tube.
Transportation of fertilized ovum to
uterine cavity in 3-4 days, the
fertilized ovum should reach the
uterine cavity for nidation.

13. CAUSES OF INFERTILITY
40 %
15 %

14. MALE FACTORS THAT CAUSES
INFERTILITY
• Defective spermatogenesis
• Obstruction of the efferent ducts
• Failure to deposit sperm
• Errors in seminal fluid

15. Defective spermatogenesis
A. Congenital: Undescended testes
are a congenital condition in which
Spermatogeneis is depressed. Vas
deferens is absent bilaterally in 1-2%
of such men.

16. Defective spermatogenesis
B. Hypospadias causes failure to
deposit sperm high in the vagina.

17. Defective spermatogenesis
D. Infection: Mumps orchitis after
puberty may permanently damage
Spermatogeneis. In chronic systemic
illnesses like bronchiectasis, the
quality of sperm is adversely affected.
Infection of the seminal vesicle or
prostate depresses sperm count.

18. Defective spermatogenesis
C. Thermal factor: The scrotal
temperature has to 10F-20F less than
the body temperature. It is raised in
conditions such as varicocele, big
hydrocele. Other causes are using
tight undergarments or working in hot
atmosphere

19. Defective spermatogenesis
E.Gonadotropin suppression: This
happens in chronic debilitating
diseases, malnutrition, heavy
smoking and with high alcoholic
consumption.

20. Defective spermatogenesis
F. Endocrine factors: follicle-
stimulating hormone (FSH) level is
seen raised in idiopathic testicular
failure. Hypoprolactinemia is
associated with impotence.

21. Defective spermatogenesis
G. Loss of sperm motility
(asthenozoospermia and abnormal
sperm morphology are seen in some
males).
H. Genetic: Common chromosomal
abnormality in azoospermic male is
Klinefelter’s syndrome (47, XXY).

22. Defective spermatogenesis
I. Iatrogenic: Radiation, cytotoxic
drugs, beta (β)-blockers,
antihypertensive, anticonvulsants and
antidepressant drugs are likely to
hinder spermatogenesis.

23. Defective spermatogenesis
J. Immunological factor: Antibiotics
against spermatozoa surface antigens
may cause infertility. This causes
clumping of spermatozoa after
ejaculation.

24. Obstruction of the efferent ducts:
The efferent ducts may be
obstructed by tubercular infections.
Surgical trauma during vasectomy or
herniorrhaphy may lead to
obstruction.

25. Failure to deposit sperm high in the
vagina (coital problems)
Erectile dysfunction
Ejaculatory defects such as
premature, retrograde or absence of
ejaculation
Hypospadias

26. Errors in seminal fluid:
Unusually high or low volume of
ejaculate (normal volume is 2ml or
more).
Low-fructose content.
High-prostaglandin content.

27. Normal semen values as determined
by World Health Organization
(WHO) are given in table
Semen
parameters
Reference value
Volume 20ml or more
pH 7.2-7.8
Sperm
concentration
20 million per ml or more
Motility 50% or more with progressive forward
motility
Morphology 15% or more in normal form
Viability 75% or more living
Leukocytes Less than one million per ml

28. CAUSES OF FEMALE
INFERTILITY
 Ovarian factors
 Uterine factors
Cervical factors
Vaginal factors (implicated)

29. Combined factors
Age of wife beyond 35 years and
advancing age in men
Infrequent intercourse (less than 4-5
per week) during fertile period
(around ovulation)
Apareunia (failure of emission of
semen/ejaculation) and dyspareunia

30. Combined factors
Anxiety and apprehension
Use of lubricants during
intercourse, which may be
spermicidal
Immunological factors (antisperm
antibiotics)

31. INVESTIGATION OF FEMALE
HISTORY
EXAMINATION
DIAGNOSTIC EVALUATION

32. HISTORY TAKING
MARRAIGE
MEDICAL & SURGICAL
MENSTRUAL
PREVIOUS OBSTETRIC
CONTRACEPTIVE PRACTICE
SEXUAL PROBLEMS

33. Examinations
General examination: Obesity,
abnormal distribution of hair and
underdevelopment of secondary sex
characteristics.
Systemic examination:
Hypertension, organic heart disease,
endocrinopathies.

34. Examinations
Gynecologic examination: Evidence
of vaginal infection, undue elongation
of cervix, uterine size, position,
nodules in the pouch of Douglass.
Speculum examination: For
presence of cervical discharge, which
if present needs to be tested for
infection.

35. DIAGNOSTIC EVALUATION
Menstrual history: Look for
evidences of ovulation such as:
Regular, normal menstrual loss
between the ages of 20 and 35.
Mid-menstrual bleeding (spotting)
or pain, or excessive vaginal
discharge suggestive of
mittelschmerz syndrome.
Features of primary dysmenorrheal
or premenstrual syndrome (PMS)

36. Diagnostic evaluation
Cervical mucus study:
Disappearance of fern pattern of the
mucus beyond 22nd day of cycle,
progesterone causes dissolution of
sodium crystals. Following ovulation,
there is a loss of stretchability or
elasticity is an evidence of ovulation.
Fern test during the cycle aids in
determining ovulation.

37. Diagnostic evaluation
Endometrial biopsy

38. Diagnostic evaluation
Sonography: Serial sonography
during midcycle can precisely
measure the Graafian follicle just
prior to ovulation (18-20mm): The
features of recent ovulation are
collapsed follicle and fluid in the
pouch of Douglas.

39. Diagnostic evaluation
Laparoscopy: Laparoscopic
visualization of recent corpus luteum
or detection of the ovum from the
aspirated peritoneal fluid to the pouch
of Douglas is the direct evidence to
ovulation.

40. Diagnostic evaluation
Insufflation test (Rubin’s test):
It is done to see the patency of
fallopian tubes. It is done by pushing
air or carbon dioxide under-pressure
through the cervical canal. If the
tubes are patent, air reaches the
peritoneal cavity. It is done in the
postmenstrual period at least 2 days
after stoppage of menstrual bleeding.

41. Diagnostic evaluation
Rubin’s test Positive findings
include:
Fall in the pressure when raised
beyond 120mm Hg.
Hissing sound heard on
auscultation on either iliac fossa.
Shoulder pain experienced by the
patient due to irritation of diaphragm
by air.

42. Diagnostic evaluation
Hysterosalpingography (HSG): In this
test, instead of air or carbon dioxide,
dye is introduced transcervically. The
test is done in the postmenstrual phase,
2 days after the stoppage of
menstruation. It is avoided if the women
as pelvic infection. It can precisely
detect the site of block in the tube. It can
reveal any abnormality in the uterus
such as fibroid or synechiae. A
disadvantage of HSG is radiation risk.

43. Diagnostic evaluation
Hysterosalpingography (HSG)

44. Diagnostic evaluation
Laparoscopic chromotubation

45. Diagnostic evaluation
Sonosalpingography: This test
involves a slow injection of
physiological saline into the uterine
cavity using a pediatric Foley’s
catheter. The catheter balloon is
inflated at the level of the cervix to
prevent fluid leak. Ultrasonography
of the uterus and fallopian is then
done. Ultrasound can follow the fluid
through the tube up to the peritoneal
cavity and in the pouch of Douglas.

46. Diagnostic evaluation
Sonosalpingography

47. MANAGEMENT OF
INFERTILITY
Management of infertility or
subfertility would depend upon the
causes identified, duration and age of
the couple, especially the female.

48. GENERAL INSTRUCTIONS
Body weight: Overweight or
underweight of any partner should be
adequately dealt with to obtain an
optimal body weight.
Smoking and alcohol: Excess
smoking or alcohol consumption to
be avoided.

49. GENERAL INSTRUCTIONS
Ideal coital frequency: Intercourse
on multiple days during the fertile
window period, which includes the
five preceding and the day of
anticipated ovulation, should be
reviewed with the couple.

50. GENERAL INSTRUCTIONS
Use of at home ‘fertility monitor’
and checking of vaginal mucus
discharge to determine the optimal
timing of intercourse may be most
helpful.

51. GENERAL INSTRUCTIONS
Use of LH surge kit: Use of the kit
can detect LH surge in urine by
getting a deep blue color of dipstick.
The test performed between 12th and
16th day of regular cycle and timed
intercourse over 24-36 hours after the
color change reasonably succeeds to
conception.

52. GENERAL INSTRUCTIONS
Avoidance of lubricants and
douches to be stressed.
The use of fertility impairing
medications should be avoided by
both partners if possible, e.g.
hormones.

53. GENERAL INSTRUCTIONS
Psychological support should be
offered as the couple may face
significant stress and sadness as the
investigations and consultations
progress.

54. MANAGEMENT OF MALE
INFERTILITY
1. General care:
Improvement of general health:
•Reduction of weight in obese
•Avoidance of alcohol and heavy
smoking
•Avoidance of tight and warm
undergarments
•Avoidance of occupation that may
elevate testicular temperature

55. 1. General care:
 Avoiding medications that
interfere with spermatogenesis
such as:
•Cytotoxic drugs, anticonvulsants,
antidepressants and beta blockers.

56. 2. Medications to treat specific
causes:
Human chorionic gonadotropin
(hCG)
Dopamine agonist (cabergoline) for
hyperprolactinemia and altered
testosterone level and to improve
libido, potency and fertility.

57. 2. Medications to treat specific
causes:
The GnRH therapy for
hypogonadism.
Clomiphene citrate to increases
serum levels of FSH, LH and
testosterone.
Antibiotics for genital tract
infections.

58. 3.Surgical treatment:
In men, whose testicular biopsy
shows normal spermatogenesis and
obstruction is suspected,
vasovasostomy may help.
Correction of hydrocele.

59. MANAGEMENT OF
FEMALE INFERTILITY
1. For ovulatory dysfunction:
Induction of ovulation using drugs
such as FSH, hCG and GnRH.
Substitution therapy: Thyroxin for
hypothyroidism, antidiabetic drugs
for diabetes mellitus.

60. MANAGEMENT OF FEMALE
INFERTILITY
2. Surgery:
Laparoscopic ovarian drilling or
laser vaporization for polycystic
ovarian syndrome (PCOS).
Surgical removal of adrenal tumor.
Tubotubal anastomosis for adhesion
in tube.

61. MANAGEMENT OF FEMALE
INFERTILITY
2. Surgery:
Cannulation and balloon tuboplasty
for block in tube.
Fimbrioplasty for fimbrial
adhesions.
Adhesiolysis for separation or
division of adhesion.
Salpingostomy to create an opening
in tube in a complete occluded tube.

62. MANAGEMENT OF
UNEXPALINED INFERTILITY
Unexplained or persistent infertility
refers to those couples who have
undergone complete basic infertility
workup and in whom no abnormality
has been detected and still remains
infertile. The reported evidence is
about 10-20%. About 60-80% of
those couple becomes pregnant
within 3 years without any treatment.

63. ASSISTED REPRODUCTIVE
TECHNOLOGY

64. DIFFERENT TECHNIQUES OF
ART
Intrauterine insemination
In vitro fertilization and embryo
transfer (NF-ET)
Gamete intrafallopian transfer
(GIFT)
Zygote intrafallopian
transfer(ZIFT)
Intracytoplasmic sperm injection.

65. Intrauterine insemination

66. In vitro fertilization and
embryo transfer (NF-ET)

67. Gamete intrafallopian transfer
(GIFT)

68. Zygote intrafallopian
transfer(ZIFT)

69. Intracytoplasmic sperm
injection

70. ROLE OF NURSE MIDWIFE
Nurses meet couple seeking help for
treatment of fertility in special centers
or clinics, where such services are
available. Those working in infertility
centers usually are the first contact
persons who coordinate various
activities for the couple’s treatment.
Their role with such couples includes
assessing, educating and counseling in
addition to therapeutic assistance as
they undergo tests and procedures.

71. ROLE OF NURSE MIDWIFE
When a couple presents with
concerns about infertility, it is
important for the nurse to understand
that men and women are very
concerned and possibly emotionally
fragile.

72. ROLE OF NURSE MIDWIFE
Before or even beginning, the
medical aspect of care is important to
understand and assist the couple to
understand their motivation for
pregnancy and to offer support. The
couple should understand and accept
that the evaluation and treatment for
infertility will be stressful and
involves both partners throughout the
process. It is important to meet the
couple together.

73. ROLE OF NURSE MIDWIFE
Nursing interventions include
assisting in reducing stress in the
relationship, encouraging
cooperation, protecting privacy and
fostering understanding.
During the period of therapy,
couples need to avoid smoking,
continue good diet, exercise, maintain
health and take folic acid
supplements, if prescribed.

74. CONCLUSION:
In this seminar I conclude that
although infertility is common in both
men and women Infertility should be
evaluated after one year of
unprotected intercourse. History and
physical examination usually will
help to identify the etiology. If the
patients fail the initial therapies then
the proper referral should be made to
a reproductive specialist.

75. SUMMARY:
Today we have discussed about
Definition of infertility, factors
contributing in fertility, causes of
male and female infertility,
management of male and female
infertility and unexplained infertility
management and role of nurse in
management of infertility.

76. BIBLIOGRAPHY
J.B.sharma Midwifery and
Gynaecological nursing .1st edition, A
vichalpublications; page no.390-400
AnnamaJacob. A comprehensive
Textbook of Midwifery&
gynaecological nursing, 4th
edition,jappee publication; page no:
857-560
Hiralalkonar DC Dutta’s Textbook
of
Gynecology.7thedition,Jaypeepublicat
ion; page no.55-57

77. THANK YOU