CHAPTER 8: NURSING CARE OF THE SUBFERTILE COUPLE

Infertility is a term used to describe the inability to conceive a child or sustain a pregnancy to birth.
Because most couples have the potential to conceive but they are just less able to do this without
additional help, the term subfertility is more often used today

I. Subfertility
- Is said to exist when a pregnancy has not occurred after at least 1 year of engaging in
unprotected coitus (Kumar et al., 2007).
- In primary subfertility, there have been no previous conceptions; in secondary
subfertility, there has been a previous viable pregnancy but the couple is unable to
conceive at present.
- Sterility is the inability to conceive because of a known condition, such as the absence
of a uterus

A. Male Subfertility Factors

• Disturbance in spermatogenesis (production of sperm cells)
• Obstruction in the seminiferous tubules, ducts, or vessels preventing movement of
spermatozoa
• Qualitative or quantitative changes in the seminal fluid preventing sperm motility
(movement of sperm)
• Development of autoimmunity that immobilizes sperm
• Problems in ejaculation or deposition preventing spermatozoa from being placed
close enough to a woman’s cervix to allow ready penetration and fertilization

1. Inadequate Sperm Count

 The sperm count is the number of sperm in a single ejaculation or in a
milliliter of semen (Kumar et al., 2007).
 The minimum sperm count considered normal is 20 million per milliliter
of seminal fluid, or 50 million per ejaculation.
 At least 50% of sperm should be motile, and 30% should be normal in
shape and form
 Cause: Increases body temperature (chronic infection from tuberculosis,
recurrent sinusitis, working at desk jobs, driving such as salesmen,
frequent hot tubs and sauna); congenital abnormalities (cryptorchidism,
varicocele); trauma to testes; surgery on or near the testicles that
results in impaired testicular circulation; and endocrine imbalances,
particularly of the thyroid, pancreas, or pituitary glands. Drug use or
excessive alcohol use and environmental factors such as exposure to x-
rays or radioactive substances.

2. Obstruction or Impaired Sperm Motility

  Obstruction may occur at any point along the pathway that
spermatozoa must travel to reach the outside: the seminiferous tubules,
the epididymis, the vas deferens, the ejaculatory duct, or the urethra
 Causes: Diseases such as mumps orchitis (testicular inflammation and
scarring because of the mumps virus), epididymitis (inflammation of the
epididymis), and tubal infections such as gonorrhea or ascending
urethral infection can result in this type of obstruction because
adhesions form and occlude sperm transport. Anomalies of the penis,
such as hypospadias (urethral opening on the ventral surface of the
penis) or epispadias (urethral opening on the dorsal surface), can cause
sperm to be deposited too far from the sexual partner’s cervix to allow
optimal cervical penetration. Extreme obesity in a male may also
interfere with effective penetration and deposition

3. Ejaculation Problems
 Causes: Psychological problems, diseases such as a cerebrovascular
accident, diabetes, or Parkinson’s disease, and some medications (e.g.,
certain antihypertensive agents) may result in erectile dysfunction
(formerly called impotence or the inability to achieve an erection).
Premature ejaculation (ejaculation before penetration) is another factor
that may interfere with the proper deposition of sperm

B. Female Subfertility Factors

 anovulation (faulty or inadequate production of ova),
 problems of ova transport through the fallopian tubes to the uterus, uterine
factors such as tumors or poor endometrial development, and
 cervical and vaginal factors that immobilize spermatozoa (Kumar et al.,
2007).
 nutrition, body weight, and exercise may be responsible.

1. Anovulation
 Which means absence of ovulation
 Causes: genetic abnormality such as Turner’s syndrome
(hypogonadism); ovarian tumors; Chronic or excessive exposure to x-
rays or radioactive substances, general ill health, poor diet, and stress;
The most frequent cause, however, is naturally occurring variations in
ovulatory patterns or polycystic ovary syndrome, a condition in which
the ovaries produce excess testosterone, lowering FSH and LH levels
 How: Maintain an ideal body weight and height, as represented by a
body mass index (BMI) of 20 to 24; For nutrition, eating slowly digested
carbohydrate foods such as brown rice, pasta, dark bread, beans, and
fiber-rich vegetables rather than food such as white bread and cold
breakfast cereals; Eating unsaturated fatty acids rather than saturated
 or trans-fatty acids. Trans-fatty acids are found in foods such as stick
margarine, commercial French fries, and doughnuts. Saturated fats are
those found in animal products such as cheese, meat, and butter.
Unsaturated fats are those derived from plant sources such as corn or
olive oil.; Healthy eating habits, exercising 30 minutes a day by walking
or doing mild aerobics

2. Tubal Transport Problems

 Causes: Scarring has developed in the fallopian tubes. This
typically is caused by chronic salpingitis (chronic pelvic
inflammatory disease); Pelvic inflammatory disease (PID) is
infection of the pelvic organs: the uterus, fallopian tubes,
ovaries, and their supporting structures.

3. Uterine Problems
 Causes: Tumors such as fibromas (leiomyomas); A congenitally
deformed uterine cavity may also limit implantation sites;
Endometriosis refers to the implantation of uterine
endometrium, or nodules, that have spread from the interior of
the uterus to locations outside the uterus (Yap, Furness, &
Farquhar, 2007). The most common sites of endometrium
spread include Douglas’s cul-de-sac, the ovaries, the uterine
ligaments, and the outer surface of the uterus and bowel

4. Cervical Problems
 Causes: Infection or inflammation of the cervix (erosion; A
stenotic cervical os or obstruction of the os by a polyp may
further compromise sperm penetration; A woman who has
undergone dilatation and curettage

5. Vaginal Problems
 Causes: Infection of the vagina

C. Unexplained Subfertility
Offer active support to help the couple find alternative solutions, such as
continuing to try to conceive, using an assisted reproductive technique,
choosing to adopt, or agreeing to a child-free life.
II. Fertility Assessment
A. Health History:

B. Physical Assessment
After a thorough history, both men and women need a complete physical
examination. For the man, important aspects of this are detection of the presence
of secondary sexual characteristics and genital abnormalities, such as the absence of
a vas deferens or the presence of undescended testes or a varicocele (enlargement
of a testicular vein). The presence of a hydrocele (collection of fluid in the tunica
vaginalis of the scrotum) is rarely associated with subfertility but should be
documented if present.
For a woman, a thorough physical assessment including breast and thyroid
examination is necessary to rule out current illness. Of particular importance are
secondary sex characteristics, which indicate maturity and good pituitary function
(see Chapter 33 for a discussion of Tanner stages). A complete pelvic examination
including a Pap test (see Chapter 11) is needed to rule out anatomic disorders and
infection

C. Fertility Testing
1. Semen Analysis: after 2 to 4 days of sexual abstinence, the man ejaculates by
masturbation into a clean, dry specimen jar. The number of sperm in the
specimen are counted and then examined under a microscope within 1 hour
(Box 8.3). An average ejaculation should produce 2.5 to 5.0 mL of semen and
should contain a minimum of 20 million spermatozoa per milliliter of fluid (the
average normal sperm count is 50 to 200 million per milliliter). The analysis may
need to be repeated after 2 or 3 months, because spermatogenesis is an
 ongoing process, and 30 to 90 days is needed for new sperm to reach maturity
(Anderson & Genadry, 2007).

2. Sperm Penetration Assay and Antisperm Antibody Testing: For impregnation to

take place, sperm must be motile enough to navigate the vagina, uterus, and a
fallopian tube to reach the ova. Although sperm penetration studies are rarely
necessary, they may be scheduled to determine whether a man’s sperm, once
they reach an ovum, can penetrate it effectively. With the use of an assisted
reproductive technique such as IVF, poorly motile sperm or those with poor
penetration can be injected directly into a woman’s ovum under laboratory
conditions (intracytoplasmic sperm injection), bypassing the need for sperm to
be fully motile.

3. Ovulation Monitoring: The least costly way to determine a woman’s ovulation

pattern is to ask her to record her basal body temperature (BBT) for at least 4
months. To determine this, a woman takes her temperature each morning,
before getting out of bed or engaging in any activity, eating, or drinking, using a
special BBT or tympanic thermometer. She plots this daily temperature on a
monthly graph, noticing conditions that might affect her temperature (e.g.,
colds, other infections, sleeplessness). At the time of ovulation, the basal
temperature can be seen to dip slightly (about 0.5° F); it then rises to a level no
higher than normal body temperature and remains at that level until 3 or 4 days
before the next menstrual flow. This increase in BBT marks the time of
ovulation, because it occurs immediately after ovulation (actually at the
beginning of the luteal phase of the menstrual cycle, which can occur only if
ovulation occurred). A temperature rise should last approximately 10 days. If it
does not, a luteal phase defect is suggested (i.e., progesterone production
begins but is not sustained). Typical graphs of BBT are shown in Figure 8.2.

4. Ovulation Determination by Test Strip: Various brands of commercial kits are

available for assessing the upsurge of LH that occurs just before ovulation.
These can be used in place of BBT monitoring. A woman dips a test strip into a
midmorning urine specimen and then compares it with the kit instructions for a
color change. Such kits are purchased over the counter, are easy to use, and
have the advantage of marking the point just before ovulation occurs rather
than just after ovulation, as is the case with BBT. They are not as economical as
simple temperature recording, but they are advantageous for women with
irregular work or daily activity schedules (e.g., working the night shift, arising at
varying times in the morning), which can make BBT measurements inaccurate.
Another type of testing kit (Fertell) contains both materials to test FSH the third
day of a woman’s menstrual cycle (an abnormally high level is an indicator that
her ovaries are not responding well to ovulation) and a sperm motility test for
the male (Milkin, 2007). The woman’s result is available in 30 minutes, the
man’s in 90 minutes. The kits are expensive but can be helpful to a couple as a
 first step in fertility testing. Be certain a woman realizes this is not a test of her
time of ovulation but a test of whether she has adequate FSH to stimulate egg
growth, so she does not use the test at the midpoint of her menstrual cycle.

5. Tubal Patency: Both ultrasound and x-ray imaging can be used to determine the
patency of fallopian tubes and assess the depth and consistency of the
endometrial lining.

a) Sonohysterography is an ultrasound technique designed for inspecting

the uterus.
b) Hysterosalpingography (uterosalpingography), a radiologic examination
of the fallopian tubes using a radiopaque medium, is a second
frequently used technique.

D. Advanced Surgical Procedures

1. Uterine endometrial biopsy: May be used to reveal an endometrial problem
such as a luteal phase defect. Endometrial biopsies are done 2 or 3 days before
an expected menstrual flow (day 25 or 26 of a typical 28-day menstrual cycle).
After a paracervical block, a thin probe and biopsy forceps are introduced
through the cervix. A woman may experience mild to moderate discomfort from
the maneuvering of the instruments. There may be a moment of sharp pain as
the biopsy specimen is taken from the anterior or posterior uterine wall.
Possible complications include pain, excessive bleeding, infection, and uterine
perforation.
2. Hysteroscopy: Visual inspection of the uterus through the insertion of a
hysteroscope, a thin hollow tube, through the vagina, cervix, and into the
uterus. This is helpful to further evaluate uterine adhesions or other
abnormalities that were discovered on hysterosalpingogram.
3. Laparoscopy: Is the introduction of a thin, hollow, lighted tube (a fiberoptic
telescope or laparoscope) through a small incision in the abdomen, just under
the umbilicus, to examine the position and state of the fallopian tubes and
ovaries (see Fig. 6.12). It allows the examiner to view the proximity of the
ovaries to the fallopian tubes. If this distance is too great, the discharged ovum
cannot enter the tube. It is rarely done unless the results of
uterosalpingography are abnormal.

III. Subfertility Management

A. Correction of Underlying Problem
1. Increasing Sperm Count and Motility: If sperm are not motile because the vas
deferens is obstructed, the obstruction is most likely to be extensive and difficult to
relieve by surgery. Ligation of a varicocele (if present) and changes in lifestyle (e.g.,
 wearing looser clothing, avoiding long periods of sitting, avoiding prolonged hot
baths) may be helpful to reduce scrotal heat and increase the sperm count.
2. Reducing the Presence of Infection: If a vaginal infection is present, the infection
will be treated according to the causative organism based on culture reports (see
Chapter 47). Vaginal infections such as trichomoniasis and moniliasis tend to recur,
requiring close supervision and follow-up.
3. Hormone Therapy: If the problem appears to be a disturbance of ovulation,
administration of GnRH is a possibility. Therapy with clomiphene citrate (Clomid,
Serophene) may also be used to stimulate ovulation (Box 8.5).
4. Surgery: Irregular line left by the surgery may result in an ectopic pregnancy (a tubal
pregnancy) if a fertilized ovum is stopped at the irregular point (Ahmad et al., 2009).
Intrauterine insemination is more commonly used today and more apt to result in a
viable pregnancy. If a myoma (fibroid tumor) is interfering with fertility, a
myomectomy, or surgical removal of the tumor, can be scheduled. For problems of
abnormal uterine formation, such as a septate uterus, surgery is also available. If the
problem is tubal insufficiency from inflammation, diathermy or steroid
administration may be helpful in reducing adhesions. Hysterosalpingography can be
repeated to determine whether these produce a therapeutic effect. Canalization of
the fallopian tubes and plastic surgical repair (microsurgery) are possible
treatments. If peritoneal adhesions or nodules of endometriosis are holding the
tubes fixed and away from the ovaries, these can be removed by laparoscopy or
laser surgery.

B. Assisted Reproductive Techniques

1. Therapeutic Insemination
- Instillation of sperm into the female reproductive tract to aid conception
(Burney, Schust, & Yao, 2007).
- The sperm is instilled into the cervix (intracervical insemination) or directly
into the uterus (intrauterine insemination). Either the husband’s sperm
(therapeutic insemination by husband) or donor sperm (therapeutic
insemination by donor or therapeutic donor insemination) can be used.
- Used if the man has an inadequate sperm count or a woman has a vaginal or
cervical factor that interferes with sperm motility
- Donor insemination can be used if the man has a known genetic disorder
that he does not want transmitted to children or if a woman has no male
partner.
- It is a useful procedure for men who, feeling their family was complete,
underwent a vasectomy but now wish to have children
- To prepare for therapeutic insemination, a woman must record her BBT,
assess her cervical mucus, or use an ovulation predictor kit to predict her
likely day of ovulation. On the day after ovulation, the selected sperm are
instilled into her cervix using a device similar to a cervical cap or diaphragm,
or they are injected directly into the uterus using a flexible catheter
2. In Vitro Fertilization
- In IVF, one or more mature oocytes are removed from a woman’s ovary by
laparoscopy and fertilized by exposure to sperm under laboratory
conditions outside a woman’s body.
- About 40 hours after fertilization, the laboratory-grown fertilized ova are
inserted into a woman’s uterus, where ideally one or more of them will
implant and grow (Van Voorhis, 2007).
- IVF is most often used for couples who have not been able to conceive
because a woman has blocked or damaged fallopian tubes. It is also used
when the man has oligospermia or a very low sperm count, because the
controlled, concentrated conditions in the laboratory require only one
sperm. IVF may be helpful to couples when an absence of cervical mucus
prevents sperm from traveling to or entering the cervix, or antisperm
antibodies cause immobilization of sperm. In addition, couples with
unexplained subfertility of long duration may be helped by IVF
- After fertilization of the chosen oocytes occurs, the zygotes formed almost
immediately begin to divide and grow. By 40 hours after fertilization, they
will have undergone their first cell division. In the past, multiple eggs were
chosen and implanted to ensure a pregnancy resulted but this technique
also resulted in many multiple births. Newborns from multiple births have a
much lower chance of surviving the neonatal period than others. For that
reason, today, only one or two fertilized eggs are chosen and transferred
back to the uterine cavity through the cervix by means of a thin catheter
- IVF is expensive (about $10,000 per cycle) and is available only at specialized
centers. There is a risk of maternal infection if bacteria are introduced at
any point in the transfer.

3. Gamete Intrafallopian Transfer (GIFT)

- Ova are obtained from ovaries exactly as in IVF. Instead of waiting for
fertilization to occur in the laboratory, however, both ova and sperm are
instilled within a matter of hours, using a laparoscopic technique, into the
open end of a patent fallopian tube.
- Fertilization then occurs in the tube, and the zygote moves to the uterus for
implantation.
- This procedure has a pregnancy rate equal to that of IVF.
- The procedure is contraindicated if a woman’s fallopian tubes are blocked,
because this could lead to ectopic (tubal) pregnancy.

4. Zygote Intrafallopian Transfer (ZIFT)

- Involves oocyte retrieval by transvaginal, ultrasound-guided aspiration,
followed by culture and insemination of the oocytes in the laboratory.
- Within 24 hours, the fertilized eggs are transferred by laparoscopic
technique into the end of a waiting fallopian tube. ZIFT differs from GIFT in
that fertilization takes place outside the body, allowing health care
 providers to be certain that fertilization has occurred before the growing
structure is reintroduced.
- As in GIFT, a woman must have one functioning fallopian tube for the
technique to be successful, because the zygotes are implanted into the
fimbriated end of a tube rather than into the uterus. This technique allows
for genetic analysis the same as IVF.

5. Surrogate Embryo Transfer

- An assisted reproductive technique for a woman who does not ovulate. The
process involves use of an oocyte that has been donated by a friend or
relative or provided by an anonymous donor (van Berkel, Candido, &
Pijffers, 2007).
- The menstrual cycles of the donor and recipient are synchronized by
administration of gonadotropic hormones.
- At the time of ovulation, the donor’s ovum is removed by a transvaginal,
ultrasound-guided procedure.
- The oocyte is then fertilized in the laboratory by the recipient woman’s male
partner’s sperm (or donor sperm) and placed in the recipient woman’s
uterus by embryonic transfer.
- Once pregnancy occurs, it progresses the same as an unassisted pregnancy

6. Preimplantation Genetic Diagnosis

- The individual retrieval of oocytes and their fertilization under laboratory
conditions have led to close inspection and recognition of differences in
sperm and oocytes.
- After the oocytes are fertilized in IVF and ZIFT procedures, the DNA of both
sperm and oocytes can be examined for specific genetic abnormalities or
specific genes such as Down’s syndrome or haemophilia

IV. Alternatives to Childbirth

A. Surrogate Mothers
o A woman who agrees to carry a pregnancy to term for a subfertile couple (Reilly,
2007).
o The surrogate may provide the ova and be impregnated by the man’s sperm.
o In other instances, the ova and sperm both may be donated by the subfertile
couple, or donor ova and sperm may be used.
o Are often friends or family members who assume the role out of friendship or
compassion, or they can be referred to the couple through an agency or
attorney and receive monetary reimbursement for their expenses.
 o The subfertile couple can enjoy the pregnancy as they watch it progress in the
surrogate

B. Adoption
o Once a ready alternative for subfertile couples, is still a viable alternative,
although today there are fewer children available for adoption from official
agencies than formerly

C. Child-Free Living
o An alternative lifestyle available to both fertile and subfertile couples. For many
subfertile couples who have been through the rigors and frustrations of
subfertility testing and unsuccessful treatment regimens, child-free living may
emerge as the option they finally wish to pursue.
o A couple in the midst of fertility testing may begin to reexamine their motives
for pursuing pregnancy and may decide that pregnancy and parenting are not
worth the emotional or financial cost of future treatments.
o They may decide that the additional stress of going through an adoption is not
for them, or they may simply decide that children are not necessary for them to
complete their family unit. For these couples, child-free living is a positive choice