INFERTILITY

Reference:
Silbert-Flagg, J & Pilitteri, A. Maternal and Child Health Nursing,
Philadelphia. Wolters Kluwer. (8th edition) Pp: 328-368
 INFERTILITY

DEFINITION

Infertility is an inability to get pregnant or to

produce a baby after 1 year of unprotected
sexual intercourse.
 TYPES OF INFERTILITY
1. Primary infertility
Pregnancy has never occurred
2. Secondary Infertility
At least one previous pregnancy has occurred, but
a successful pregnancy has not been realised at
the current time.
3. Relative Infertility or impaired fertility
A set of conditions that may impede or postpone
pregnancy but often can be corrected.
4. Sterility
Conception cannot occur and the causative factor
cannot be reversed.
 CAUSES OF INFERTILITY

The cause may be present in either

the man
the woman
or both of them.
 FEMALE FERTILITY FACTORS
Age: Fertility declines with age.
Ovulation problems: Ovulation failure may be due to problems
in the hypo-thalamic-pituitary ovarian axis or disorder of the
thyroid or adrenal glands. These may lead to oligomenorrhea
or amenorrhea due to decreased serum progesterone level.
Previous Sexually Transmitted Diseases: Chlamydia or
gonorrhea places the woman at risk of tubal damage or
blockage or pelvic scaring, Past pelvic infection may result in
scar tissue formation.
Diseases processes: Thyroid disorders, diabetes,
hypertension, cardiovascular diseases, kidney disorders,
infections.
Nutritional status: Body-fat ratio of less than 10% is
considered malnutrition and this may result in anovulation,
Obesity
 FEMALE FERTILITY FACTORS
Athletes or anorexic women may have reduced pituitary
hormones that may halt ovulation.
Physical abnormality / anatomy of the reproductive organs
e.g., retroflexed uterus
Ovarian masses /cysts which may interfere with ovulation
Problems with the uterine environment (endometrium):
Endometritis, Endometriosis
Recurrent ectopic pregnancies, Post operative inflammation
of the tubal lumen.
Chronic or excessive exposure to radioactive substances or
x-ray.
Uterine fibromas
Cervical mucus problems
Vaginal pH (acidic destroying the motility of the sperm.
MALE-FEMALE FERTILITY FACTOR

Mucus sperm incompatibility

Sperm immobilizing or sperm-agglutinating
antibodies in their blood plasma that act to
destroy sperm in the vagina or cervix.
 MALE FERTILITY FACTORS
Sterility after infections like gonorrhea or
tuberculosis, causing blockage in the vas deferens.
Exposure to environmental toxins like pesticide,
herbicides may affect the quality or quantity of
sperm
Exposure to radioactive substances or x-ray.
Drug or alcohol abuse .
Problems related to sperm production or motility
(movement)
Constant use of hot tubs
Too tight fitting underwear and pants
 MALE FERTILITY FACTORS
Physical abnormalities of the genitals e.g. cryptorchidism
(undescended testes), Testicular atrophy as a result of post
pubescent mumps
varicose veins in the scrotum increases the temperature
within the testes.
Surgery on or near the testicles that result in impaired
testicular circulation or previous herniorrhaphy resulting in
scar tissue formation
Previous vasectomy for sterilization
Impotence (inability for the male to achieve or maintain
erection
Pre-mature ejaculation
Psychological factors like job & financial stress, fatigue,
depression, anxiety surrounding sexual intercourse, illness.
Trauma to the testes
Hypertrophy of the prostrate gland
 Investigations - Male
Semen analysis: Semen is collected by
masturbation. Better results if done after 2-3
days of abstinence. Do not use ordinary
condoms for specimen collection.
Normal Findings
Volume more than 2 mL
pH 7-8
T. sperm count more than 20 million/mL
Liquefaction Complete in 1 hr
Motility 50% or more
Morphology 30% or more normal
 Instructions for collection of sperms
Use clean, dry plastic or glass container with a
secure lid for sperm collection.
Collect the specimen as close as possible to
usual schedule of sexual activity.
Avoid using any lubricants or collecting sperm
into a condom.
Collect also the pre-ejaculate fluid.
After collection close the container securely and
record the time.
Keep the specimen at body temperature while
transporting it (Carry it next to chest).
Transport to lab immediately so that it can be
analyzed within 1 hour of collection.
 Investigations - Female
Evaluation of ovulation
1. Basal body temperature
2. Cervical mucus method
3. Hormonal assessment
a) FSH and LH levels
b) Progesterone assays: 5 ng/mL on 3rd
day and 10 ng/mL on 21st day (7th
day postovulation).
c) Prolactin
d) TSH
e) Androgen levels
Investigations - Female
Endometrial biopsy: Done 10-12
days after ovulation
Transvaginal ultrasound (TVS)
Postcoital test (Huhner test): Done
1 or 2 days before ovulation.
Cervical mucus is aspirated 2- 8
hours after unprotected
intercourse.
 Investigations - Female
Tubal factors
1. Hysterosalpingography (HSG): X-ray
visualization of the uterus, fallopian tubes
and peritoneal cavity after injection of a
radio opaque dye. Should be done on
the 5th 10th days of menstrual cycle.
2. Sonohysterography
3. Hysteroscopy
4. Laparoscopy
MANAGEMENT OF INFERTILITY
 Problems in the Male
Reduce Sperm Count or Motility
Reduction of heat to the scrotum.

Hormonal treatment with Clomid to increase sperm count.

Artificial Insemination with husband sperm

Here the sperm is directly delivered to the cervix by means

of a cup device similar to a cervical cap, which allows the
cervix to rest in the seminal pool.

Psychological factors
Counseling and referral to support groups where available
can be very helpful.
 Medical Interventions
This will depend on the cause of the problem.
Problems in the Female
Ovulation failure: This can be treated with dopamine
receptor agonist which lowers prolactin levels allowing
resumption of ovulation e.g. bromocriptine.
Clomid (Clomiphene citrate) is a common drug of choice for
women with decreased serum progesterone level, this drug
enhances follicular development and induces ovulation.
For Uterine problems: Congenital anomalies, fibroid etc,
surgical correction or removal.
Cervical mucus problem: Medications are available to
restore normal mucus producing patterns.
For Tubal problems: Correction of tubal blockage, and some
may be difficult to correct.
In this situation several techniques of Assisted Reproductive
Technology - IVF (In Vitro Fertilization) and ICSI (Intra
cytoplasmic sperm injection)
 Male- Female Factor
Cervical mucus problem/ mucus sperm
incompatibility:
Intra-uterine insemination a type of
artificial insemination by injecting the
concentrated sperm directly into the
uterine cavity by means of a slender
flexible plastic catheter
 Assisted reproductive techniques
Artificial insemination:
Instillation of sperm into the female
reproductive tract to aid conception. Sperms
can be instilled into the cervix (Intracervical
insemination) or into the uterus (Intrauterine
insemination). Either husband s sperms or
donor sperms can be used. Sperms can be
cryopreserved (frozen) for future use.
 In Vitro Fertilization (IVF):
One or more mature oocytes are removed from a
woman s ovary by laparoscopy and fertilized by
exposure to sperms under laboratory conditions
outside the woman s body.
After 40 hours the fertilized ova are transferred into
the woman s uterus where one or more of them will
implant and grow.
Indicated in women with damaged fallopian tubes
and in men with low sperm count.
Intracytoplasmic sperm injection: Injecting the
sperm directly under the zona pellucida. Fertilization
is possible with only one sperm.
Gamete intrafallopian transfer (GIFT):
Similar to IVF, instead of fertilization
waiting to occur in the laboratory using a
laparoscopic technique both ova and
sperm are instilled into the patent end of
the fallopian tube. Fertilization occurs in
the FT and zygote moves into the uterus
for implantation.
Contraindication: Women with tubal block
Zygote intrafallopian transfer (ZIFT):

Oocytes are retrieved by transvaginal ultra sound guided

aspiration followed by culture and insemination of
oocytes in the lab.

Within 24 hours fertilized eggs are transferred by

laparoscopic technique into the end of the fallopian tube.

Contraindicated if there is a block in the FT.

 Other methods
Surrogate embryo transfer
Surrogate mother
Adoption
Child-free living
 Nursing Diagnoses
Anxiety/fear R/T possible outcome of
infertility testing.
Low self-esteem R/T inability to conceive.
Deficient knowledge regarding measures
to promote fertility.
Anticipatory grieving R/T failure to
conceive or sustain pregnancy.