05/10/2009

SEMINAR ON

SUBMITTED TO

SUBMITTED BY

Mrs. Jayabala Joshi.

Dr.D.Y.Patil College of Nursing

Ms. Martha Waidande.

Dr.D.Y.Patil College of Nursing

Pimpri Pune - 18

05/10/2009

SUBMITTED ON :

Pimpri Pune -218

05 / 10 / 2009.

DEFINITION
Fertility is defined as the capacity to
conceive or reproduce.
Infertility is defined as a failure to
conceive within one or more years of
regular unprotected coitus.
Infertility is the inability to achieve
conception after one year of
unprotected
intercourse.
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INCIDENCE
According to statistics by the Centers for
Disease Control (CDC)

6.1 million women between the ages of

15 to 44 have an impaired ability to have
children.

2.1 million married couples are

experiencing infertility.

9.2 million women had made use of

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infertility
services.
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INCIDENCE

..Contd.

WHO survey report 2000 reveals

Incidence of infertility as 12-13.5 %
among married couples.
80 % of the couples achieve
conception within one year of regular
intercourse ( 4-5 times in a week )
10 % will achieve by the end of 2nd year
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% will remain infertile by the end of

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TYPES OF INFERTILITY
1. PRIMARY INFERTILITY
When a couple has never been pregnant
either the woman has never conceived or
the man has never fathered a child.

2. SECONDARY INFERTILITY
Secondary infertility refers to women who
have achieved pregnancy and given birth
in the past, but are now having difficulty
conceiving.

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TYPES OF INFERTILITY..Contd.
3. IDIOPATHIC INFERTILITY
No definite cause for the infertility can be
found.

4. RECURRENT MISCARRIAGE
Women who experience recurrent
miscarriage may also receive a diagnosis
of infertility if they experience two or more
successive miscarriages.
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CAUSES OF INFERTILITY

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CAUSES OF INFERTILITY
1. ENDOMETRIOSIS
1/3rd of infertile women have endometriosis

Endometrial tissue outside of uterus

Anatomic distortion, adhesions
Ovarian damage (endometrioma)
Substances
that impair ovulation, fertility,
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CAUSES OF
INFERTILITY
Cont....
2. TUBAL BLOCKAGE

Due to PID because it leaves scar tissue &

adhesions as a result of inflammation
tubes may be kinked or twisted.
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CAUSES OF INFERTILITY

Cont....

3. PREVIOUS SURGERY
Previous surgery like appendectomy,
repair of a tube after ectopic pregnancy
may cause adhesions or scaring.
4. Use of IUD or progesterone only oral
contraceptives increases risk of ectopic
pregnancy.
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CAUSES OF INFERTILITY

Cont....

5.OVULATION ANOMALIES (ANOVULATION )

Failure of the ovaries to produce, mature or
release eggs is an imbalance of harmones.

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CAUSES OF INFERTILITY

Cont....

6. CERVICAL MUCOUS PROBLEMS

Hormonal deficiencies that maintain the

thick acidic property of cervical mucus
so it is hostile to sperm.

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CAUSES OF INFERTILITY

Cont....

7. INSUFFICIENT OESTROGEN &

PROGESTERONE PRODUCTION
Excessive androgen production, increased or
decreased FSH, LH Levels. The production FSH
stimulates follicle to ripen & causes the
production of Progesterone. Production of
estrogen is influenced by the levels of circulating
prolactine from the pituitary gland.

8. IMMUNOLOGIC FACTORS
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CAUSES OF INFERTILITY

Cont....

9.VARICOCELE
Is a varicose or swollen vein in the
testicle. Swelling elevates the temperature
within the testis. It retards or destroys the
process of spermatogenesis.
INCIDENCE 35 % in the infertile population.
10.COMBINED CAUSES
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FACTORS RESPONSIBLE FOR

INFERTILITY
1.
2.
3.
4.
5.
6.
7.
8.

Coital frequency
Age
Smoking
Exercise and weight loss
Diet
Stress
Medical conditions
Use of drugs and chemicals

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FACTORS RELATED TO SPERM

AND OVULATION
1. Healthy spermatozoa ( male factor )
2. The spermatozoa should undergo
changes(capacitation,acrosome reaction )
and acquire motility. ( Cervical factor )
3. The motile spermatozoa should ascend
through the cervix into the uterine cavity
and the fallopian tubes.
4 There should be ovulation.(Ovarian factor )
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FACTORS RELATED TO SPERM

AND OVULATION . Contd.
5. The fallopian tubes should be patent and the
oocyte should be picked up by the fimbriated
end of the tube. ( Tubal factor )
6. The spermatozoa should fertilize the oocyte at
the ampulla of the tube.
7. The embryo should reach the uterine cavity
after 3-4 days of fertilization.
8. The endometrium should be receptive for
implantation
and the corpus Luteum should18
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function adequately.

INVESTIGATIONS OF INFERTILITY
Objectives of investigations

To detect the etiological factors.

To rectify the abnormality in an

attempt to improve the fertility.

To give assurance with explanation to

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the
couple if no abnormality is detected.
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BASIC INVESTIGATIONS
1.

2.

MALE
HISTORY

Age duration of marriage,history of

previous marriage

General medical history

Surgical history

Occupational history

Sexual history

Social habits
EXAMINATION

General and specific examination

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Seminal fluid analysis

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BASIC INVESTIGATIONS Contd

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BASIC INVESTIGATIONS Contd

Normal semen values
Volume
2.0 ml or more
PH
7.2 7.8
Sperm concentration 20 million / ml or more
Total sperm count
> 40 million per ejaculate
Motility
50 % or more progressive
forward motility
Morphology
15 percent or more
normal form
Viability
75 % or more living
Leucocytes
Less than 1 million / ml
Sperm agglutination
< 2 ( scale 0-3 )

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BASIC INVESTIGATIONS
3.

Contd

MALE
INDEPTH EVALUATION
Serum FSH, LH, Testosterone, Prolactin
and TSH
Fructose content in the seminal fluid
Testicular biopsy

4.

TRANSRECTAL ULTRASOUND ( TRUS )

5.

VASOGRAM

6.

IMMUNOLOGICAL TEST

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BASIC INVESTIGATIONS
1.

2.

FEMALE
HISTORY

General medical history

Surgical history

Menstrual history

Previous obstetric history

Contraceptive practice

Sexual problems
EXAMINATION

General and specific examination

Gynaecological examination
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Speculam examination

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BASIC INVESTIGATIONS
3

Contd

CONFIRMATION OF OVULATION
The various methods used to detect are indirect,direct and
conclusive.

A.

Indirect

B.

Direct

C.

Conclusive

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BASIC INVESTIGATIONS

Contd..

Indirect causes are

i. Menstrual history
ii. Basal Body Temperature ( BBT ) Assessment
Temp to be taken with a special thermometer every
morning before getting out of bed.
BBT increases slightly at ovulation & remain
increased until menstruation or pregnancy.
BBTS are taken in same manner as for fertility control.
Evidence of follicle development, ovulation & corpus
luteum development would be seen if temperature
changes persisted for 12-14 days before menses.
Temperature chart for at least 4 cycles.

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BASIC INVESTIGATIONS
iii.

Contd

Cervical mucus study

After ovulation the cervical mucus becomes thick &

sticky and can be stretched between the fingers.( A
sign known as spinbarkeit )
If the mucus is mixed with semen or contraceptive
foams or an infection is present, the result may be
inaccurate. Some women may feel uncomfortable
touching their genitals and mucus.
Cervical mucus examined at ovulation & after
intercourse to determine whether changes occur
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that promote

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BASIC INVESTIGATIONS

Contd

Postcotial test (Sims-Huhner)

Intercourse (2-12 hrs) for test Look at: pH, Sperm,
Spinnbarkeit, Ferning Cellularity, Sperm Shaking,
Sperm Agglutanation

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BASIC INVESTIGATIONS

Contd

iv. Hormone estimation

Testicular dysfunction causes rise in
FSH and LH.
Low level of FSH and LH suggest
hypogonado trophic gonadism.
Eleveted prolactin due to pituitary
adenoma may cause impotency.
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BASIC INVESTIGATIONS

Contd

v. Vaginal Cytology
Maturation index shifts to the left from the
midcycle to the midsecond half of cycle
due to the effect of progesterone.

vi. Endometrial Biopsy

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BASIC INVESTIGATIONS
vii. Sonography

Contd

Serial sonography during midcycle measures

the graafian follicle before ovulation(18 to 20 mm)
Features of ovulation seen are collapsed follicle
and fluid in the pouch of douglas.
Hysteriosalphigiography To rule out uterine or
tubal abnormalities.

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BASIC INVESTIGATIONS

B. Direct

Contd

laproscopy

C Conclusive -

Pregnancy

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ADVANCED MANAGEMENT OF INFERTILITY

COUPLE INSTRUCTIONS
Assurance

Body weight
Smoking and Alcohol
Coital problems
MALE INFERTILITY TREATMENT
1. General care
Counselling
Use of vitamins E, C, D, B12.
Medications like Clomiphene citrate 25 to 50 mg
orally for 25 days with rest for 5 days for 3
cycles. It increases of sr level of FSH, LH and
testosterone.
In genetic abnormality artificial insemination of
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donor
sperms.
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ADVANCED MANAGEMENT OF INFERTILITY

Contd
MALE INFERTILITY TREATMENT
2. Surgical care
Microsurgeries like vasoepididymostomy
or vasovasostomy if patient is azoospermic.
Correction of varicocele
Orchidopexy in undescended testies

3. Impotency
Psychosexual treatment
For erectile dysfunction sildenafil (25 to 100mg
4. Assisted reproductive technology ( ART )
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ADVANCED MANAGEMENT OF INFERTILITY

Contd
FEMALE INFERTILITY TREATMENT
1. General care
Psychotherapy
Reduction of weight
2. Drugs
Medications like Clomiphene citrate 50 mg
to 250 mg orally for 5 days for 6 cycles. It
blocks the estrogen receptors in the
hypothalamus
In genetic abnormality artificial insemination
of donor sperms.
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ADVANCED MANAGEMENT OF INFERTILITY

Contd
FEMALE INFERTILITY TREATMENT

3. Surgery
Laproscopic ovarian drilling ( LOD )
Tubal surgeries
Uterovaginal surgeries
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ASSISTED REPRODUCTIVE TECHNOLOGY

1.Intrauterine insemination ( IUI )

IUI may be either AIH ( Artificial
insemination Husband ) or AD (Artificial
insemination of donor or a combination of
both.
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ASSISTED REPRODUCTIVE TECHNOLOGY

Contd
2. Gamete intrafallopian transfer ( GIFT )
Both the sperm and unfertilised oocytes are
transferred into the fellopian tubes.
3. Zygote intrafallopian transfer ( ZIFT )

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ASSISTED REPRODUCTIVE TECHNOLOGY

Contd

INVITRO FERTILIZATION ( IVF)

IVF or In Vitro Fertilization is a method of
assisted reproduction to increase the
possibility of pregnancy.
As the term in vitro fertilization or test tube
baby explains itself, it is the procedure to
fertilize eggs with sperm outside the human
body.
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ASSISTED REPRODUCTIVE TECHNOLOGY

Contd

INDICATIONS OF IVF

Blocked or damaged fallopian tubes

Abnormal sperm,
Endometriosis or immunologic problems,
other infertility treatment,
Advanced maternal age.

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ASSISTED REPRODUCTIVE TECHNOLOGY

Contd

Procdures of IVF & ET

1. Controlled Superovulation (COH)
(Clomiphene, hMG, uFSH, rFSH )
2. Monitoring (Ultrasound, E2)
3. Egg retrieval & IVF (or ICSI)
4. Embryo culture
5. Embryo Transfer (ET)
6. Luteal phase support (progesterone)
7. Pregnancy
test
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ASSISTED REPRODUCTIVE TECHNOLOGY

2. Ultrasound monitoring of follicles Contd

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ASSISTED REPRODUCTIVE TECHNOLOGY

Contd.

3. Ultrasound Guided Oocyte Retrieval

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ASSISTED REPRODUCTIVE TECHNOLOGY

Embryo Culture

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Contd

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ASSISTED REPRODUCTIVE TECHNOLOGY

5. Embryo Transfer

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Contd

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ASSISTED REPRODUCTIVE TECHNOLOGY

Contd

Intracytoplasmic sperm injection (ICSI)

ICSI is a highly technical procedure designed to
insert a sperm into the cytoplasm of egg using a
thin glass tube under the special microscope
with a manipulator.

Indications:

Severe male factor infertility

Poor quality eggs with thickened shell (zona)
Prior or repeated fertilization failure with standard
IVF
Anti-sperm antibodies
Use of surgically retrieved sperm directly from the
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epididymis

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ASSISTED REPRODUCTIVE TECHNOLOGY Contd

Intracytoplasmic sperm injection (ICSI)

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ALTERNATIVES TO INFERTILITY
1. Surrogacy
Embryos are transferred to the uterus of
another woman who is willing to carry
the
pregnancy on behalf of the infertile
couple.
2. Adoption
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ETHICAL AND LEGAL ISSUES IN

INFERTILITY
1. Artificial insemination by donor
Proper consent of her husband is taken.
2. Surrogacy
Proper consent of surrogate mother is taken.
Total responsibility of rearing parents if child born
with birth defects.
3. Frozen embryo
Should not be bought or sold.
4. Issues related to donor insemination
Use of only one donor for each attempt.
Proper consent and contract accepting the
resultant offspring as legal heir.
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APPLICATION OF NURSING THEORY

HILEGARD E. PEPLAU
THEORY OF INTERPERPERSONAL RELATION
Details of the Hildegard
Born in Pennsylvania in 1909. Started her
carrier from a diploma nursing program in 1931.
1947 MA in psychiatric nursing from Colombia
University, Newyork.
1953 Published book on interpersonal
relationship in nursing.
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APPLICATION OF NURSING THEORY

Contd.

In 1974 got retired & was recognized all

over as a nurse.
Nursing can be viewed as an interpersonal
process as it involves interaction between
two or more individual with a common goal.
For developing interaction between nurse
and patient the nurse has to choose
sequential pattern and different skills and
assume
various roles etc.
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APPLICATION OF NURSING THEORY Contd

Four phases in interpernal relationship by peplau

Oridentation : Problem defining phase.
Identification : Selection of appropriate
professional assistance.
Exploitation : Use of assistance for problem
solving.
Resolution : Termination of professional
relationship
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ROLE OF A NURSE IN INFERTILITY

MANAGEMENT
1. Involved with couples who undergoing
fertility treatment.
2. Should be aware of the types of
treatment that are currently available and
stresses that the couple has endured
during the process.
3. Reduce stress in relationship
4 Encourage co-operation, protect privacy.
5 Refer couple to appropriate resource
when
necessary.
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ROLE OF A NURSE IN INFERTILITY

MANAGEMENT
Contd
6. Advice to couple to avoid smoking
7. Emphasis on diet, exercise, stress
reduction techniques, health
maintenance and disease prevention
programs.
8. Psychological support
9. Assist with different infertility
treatments.
10. Create awareness about ethical and
legal
issues.
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NURSING PROCESS
1. Altered health maintenance related to
ineffective coping mechanisms in one or
both partners.
2. Self-esteem disturbances related to loss of
reproductive abilities.
3. Knowledge deficit related to menstrual
cycle, sexual physiology.
4. Knowledge deficit related to advance
management of infertility.
5. Altered sexual pattens related to treatment
procedures.

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Please do not give up.

But do not wait too long.
Where is a will, there is a way.

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