SUBJECT: OBSTETRIC AND GYNECOLOGIC NURSING

SEMINAR ON: INFERTILITY

TOPIC: PRIMARY AND SECONDARY CAUSES &

DIAGNOSTIC PROCEDURES

SUBMITTED TO: SUBMITTED BY:

PROFF.MRS SONEY TOPPO MS. RACHANA JOSHI
ASSOCIATE PROFESSOR. M.SC.N PREVIOUS YEAR
CCON CCON

DATE OF SUBMITION:
 INFERTILITY
INTRODUCTION: Infertility is defined as the couples inability to achieve pregnancy after 1 year of
unprotected intercourse ( using no birth control method). In United States, infertility is a major
medical & social problem, affecting 10% to 15% of the reproductive age population. In 20% the
infertility is unexplained. The remaining 80% involve medical causes equally distributed between man
& women.

Women’s infertility may be related to anovulation, uterine or cervical factors, blocked fallopian tubes,
or endometriosis while men’s infertility is related to sperm quality or sprem production.

Most infertility cases (80%- 90%) are treated with medication or surgery.

Definition of infertility

[Figure.1: Who is affected by infertility?]

 Infertility is defined as a failure to conceive within one or more years of regular

unprotected coitus. Although often the woman is blamed, infertility occurs in both men and
women. In many developing countries, including Ethiopia, having children is one of the
principal mechanisms maintaining the cohesion of the family. If a couple is unable to have
children, it can create an unhappy marriage and result in divorce, even when both the husband
and wife are infertile. In most African countries, a man’s wealth is measured by the number of
children he has. In rural areas, children are an important asset, as they will work on the land
and care for their aged parents.

INCIDENCE: Generally worldwide it is estimated that one in seven couples have problems in
conceiving. In India most of these cases women is the factor. Fertility problems affect one in seven
couples in United Kingdom. In Britain, male factor infertility accounts for 25% of infertile couples,
while 25% remain unexplained. 50% are female causes with 25% being due to anovulation & 25%
tubal problems. In Sweden approximately one third of these cases the man is the factor, in one third
women is the factor & in the remaining one third the infertility is a product of factor on both part.

Types of infertility

There are two types of infertility: primary and secondary.

Primary infertility is when a couple have never had children, or have been unable to achieve
pregnancy after one year of living together despite having unprotected sexual intercourse.

Secondary infertility is when a couple have had children or achieved pregnancy previously, but are
unable to conceive at this time, even after one year of having unprotected sexual intercourse.

Secondary infertility occurs more commonly than primary infertility, especially in developing
countries where sexually transmitted infections are common. In many countries, induced abortion
(intentionally done) contributes much to secondary infertility. Generally, it accounts for 60% of the
total number of infertility cases.

ETIOLOGY: Major causes of infertility are

Causes of infertility
The causes of infertility are varied and complex. According to studies from around the world, both
men and women are affected by infertility: about 40–60% of causes are linked to female factors, and
20–40% are related to male factors.

[Figure.2: Normal male reproductive organs]

It is important to understand the anatomical, physiological and psychological conditions affecting
fertility in women and men, both of whom should normally be able to conceive. Firstly, a man has to
have normal functioning reproductive organs (Figure.2) capable of producing normal sperm in
sufficient numbers, and he has to be able to transfer them successfully to the woman’s reproductive
system through sexual intercourse.
Similarly, the woman’s reproductive system should function normally and be able to produce healthy
eggs, have normal fallopian tubes and uterus and produce normal cervical mucus. See Figure.3 of the
female reproductive organs.

[Figure .3 Normal female reproductive organs.]

To achieve normal physiological functions and processes, the endocrine (hormone-producing) glands
of both the man and woman involved in reproduction must function normally. In addition,
psychological and social conditions can influence the timing and frequency of sexual intercourse,
which in turn can influence the chance of getting pregnant.
.
FACTORS RESPONSIBLE FOR FERTILITY

☻ Healthy spermatozoa should be deposited high in vagina.

☻ The spermatozoa should undergo changes and acquire motility.

☻ The motile spermatozoa should ascend through the cervix into the uterine cavity and the
fallopian tubes.
☻ There should be ovulation.

☻ The fallopian tube should be patent and the oocyte should be picked up by the fimbriated end
of the tube. Fertilization.

☻ The spermatozoa should fertilize the oocyte at the ampulla of the tube.

☻ The embryo should reach the uterine cavity after 3-4 days of fertilizations.
 ☻ The endometrium should be prepared for fertilization and the corpous letuem should function
adequately.

CAUSES OF FEMALE INFERTILITY

(A). PRIMARY INFERTILITY

1. SYSTEMIC DEFECTS:

♀ AGEà ABOVE 35 YEARS

Age is an important factor in both women and men. In many women fertility declines
as they age, especially over 35 years of age when the quality of eggs remaining in the
ovaries is lower than when the women were younger. In men, sperm motility is reduced
as they age, but overall fertility is not affected as much. There are many case reports
describing men having children even after the age of 90 years

♀ OBESITY,TOBACCO SMOKING .

♀ PSYCHOLOGICALà

Mental disharmony between husband and wife and fear of doing sex with husband.

♀ IMMUNOLOGICALà Anti sperm antibodies in cervical mucus (uncommon

factor) In rare cases, the cervical mucus and fluids in the vagina may contain chemicals
(antibodies) that inhibit sperm.

2. SEXUAL DYSFUNCTION

1. LACK LIBIDO.

2. INFREQUENT SEX DUE TO COUPLE STAYING APART.

3. EXHAUTION DUE TO OVERWORK.

4. VAGINISMUS. Extreme spasm of the vaginal muscles (vaginismus) during

intercourse can prevent penetration of the penis, and so result in infertility.

3. ANOVULATION

ENDOCRINE CAUSEà
 ♀ AMENORRHOEA

♀ SKIPPING MENSES

♀ DYSFUNCTIONAL UTERINE BLEEDING

♀ POLY CYSTIC OVARIAN DISEASES

♀ HYPOTHYRODISM

♀ HYPERPROLACTINAEMIA when there is a high level of the hormone prolactin,

produced by the pituitary gland, it inhibits ovulation (hyper-prolactinaemia). Other
factors that can prevent or inhibit ovulation include ovarian tumors, thyroid gland
disorder, stress and malnutrition.

♀ PREMATURE MENOPAUSE

♀ OVULATORY IRREGULARITIES Ovulation disorders in the hypothalamus-pituitary-

ovarian system are associated with an absence of ovulation

♀ NON-FUNCTIONING OVARY

♀ HYPERANDROGENISM

DRUGà
♀ ANTIPSYCHOTIC DRUG

♀ ANTIEPILECTIC

PATHOLOGICAL DEFECTS

♀ VAGINAL àTOUGH TENDER HYMEN & NARROW VAGINAL In extremely rare

cases, conditions like a vaginal septum (a tissue in the vagina developing abnormally in
the womb) that inhibits sperm transportation, and even the congenital absence of the
vagina, can be causes of infertility

♀ INTROITUS CAUSE POOR PENILE PENETRATION INTO VAGINA.

CERVICALà STENOSED CERVIX,INTRACERVICAL FIBROUS OBSTRUCTION ,

CERVICAL POLYP. In some case the cervical canal is too narrow and prevents the passage
of sperm into the uterus. Hormone imbalances (such as low oestrogen levels) can cause
inadequate cervical mucus, or make it so thick that it blocks sperm transport

UTERINEà HYPOPLASIA,ANOMALY,SUBMUCOUS FIBROID POLYP OR

ENDOMETRIAL POLYP.
When there is abnormal development of the uterus (congenital malformation), or abnormal growths in
the uterus (fibroids), adhesion of the uterus due to infection or abortion can affect the possibility of
pregnancy, either by interfering with the transport of male sperm, or with embryo implantation.
TUBAL INFLAMMATORY BLOCKAGE In women, there are many diseases which cause
inflammation of the reproductive tract, resulting in scarring and the sticking together of tissue to
create blocks. In this regard, sexually transmitted infections are one of the major causes of
infertility. If it is left untreated, gonorrhea and Chlamydia can infect the fallopian tubes, the
uterus and ovaries. These can cause pelvic inflammatory disease (PID), which occasionally has
no symptoms and so goes unnoticed (silent PID), causing scarring of the fallopian tubes and
blocking the egg from travelling down the tubes to meet the sperm. After one episode of PID, a
woman has an estimated 15% chance of infertility, while after two episodes the risk rises to
35%, and after three episodes the risk of infertility is nearly 75%.
♀ OVARIANà CYST, CHROMOSOMAL(TURNER SYNDROME)

♀ PERITONEAL FACTORà ADHESIONS

♀ IMPLANTATION DISORDERà CORPUS LEUTEM INSUFFICIENCY &

REPEATED PREGNANCY LOSS.

(B). SECONDARY INFERTILITY

♀ SHEEHAN SYNDROME: There is a history of severe post partum hemorrhage, Shock or
severe infection. And features are very common they are falling lactation, loss of pubic and
axillaries hair, lethargy, hypotension, secondary amenorrhea and atrophy of breast and
genitalia.

♀ AMENORRHOEA: Absence of Menstruation.

♀ ENDOMETRIAL TUBERCULOSIS: the uterus is involved 80% of cases. Basal layer of the
endometrium is mainly affected and after each menstrual shed off of a endometrial cavity re-
infection occurs from the layers of a basal layer, this leads to adhesion formations this may
cause infertility.

♀ CERVICAL AND VAGINAL STENOSIS

In some case the cervical canal is too narrow and prevents the passage of sperm into the uterus.
Hormone imbalances (such as low estrogen levels) can cause inadequate cervical mucus, or
make it so thick that it blocks sperm transport

♀ CORNUAL BLOCK

♀ TUBECTOMY

♀ POST MTP postpartum and post-abortion infection can also cause PID, which may lead to
infertility
 CAUSES OF MALE INFERTILITY

(A). PRIMARY INFERTILITY

1. SYSTEMIC DEFECTS
♂ ELDERLY AGE

♂ OBESITY(COITAL DIFFICULTY)

♂ TOBACCO , SMOKING, DRINKING:

Drinking large amounts of alcohol can also reduce production of testosterone (the male
hormone) and cause shrinking and/or weakness of the testes. Excessive smoking and drug
abuse.

♂ DIABETES MELLITUS certain chronic diseases like diabetes can reduce the ability to have,
and maintain, an erection due to vascular changes.

♂ FURNANCE WORKER excessive heat due to wearing tight underwear, or working for long
periods near a heat source, can reduce the production and motility of sperm.

♂ TIGHT UNDER WEAR

♂ IMMUNOLOGICà AGLUTINATING AND IMMOBILISING ANTISPERM

ANTIBODIES, UNCOMMON FACTORS.

2. COITAL DYSFUNCTION
Certain psychological conditions, like emotional, psychological or physical stress, can result in the
inability to maintain an erection, and the inability to ejaculate normally inside the vagina. Impotence
and premature ejaculation, where the man ejaculates before the penis is inside the woman’s vagina, are
another common cause.

♂ ERECTILE IMPOTENCY

♂ IGNORANCE TO DO PROPER SEX

♂ SPERM DEFECTàOLIGOZOOSPERMIA

♂ DRUGSà ANTIHYPERTENSIVES , ANTIEPILEPTICS

Other factors which contribute to a man not achieving normal sexual intercourse include neurological
damage due to leprosy, taking medications such as methyldopa (an anti-hypertensive drug)
 ♂ ENDOCRINALà HYPOTHALAMIC HYPOGONADISM

HYPOTHYROIDISM

4. PATHOLOGICAL
TESTESà MUMP ORCHITIS, CHROMOSOMAL KLINEFELTER SYNDROME.
Many disorders lead to abnormal or reduced sperm production, and can result in it stopping altogether.
For example, mumps (in Amharic, joro degif) contracted in childhood can lead to inflammation and/or
shrinking of the testes, thereby stopping sperm production in adulthood.
♂ DUCTAL OCCLUSIONà INFLAMMATORY(CHLAMYDIAL,
GONOCOCCAL,TUBERCULAR) AT EPIDYDIMIS,VAS DEFERENS.

Many diseases can cause inflammation of the vas deferens, or sperm tube, and result in scarring which
can block the tube passing sperm from the testicles or testes. Infections from untreated sexually
transmitted infections, such as gonorrhea and Chlamydia, can also ascend via the urethra. Other
conditions which can cause inflammation of the epididymis in the testes and disrupt the production of
sperm are tuberculosis, and the abnormal growth of tumors in the testicles.
(B). SECONDARY INFERTILITY
♂ VASECTOMY

Unexplained infertility
If there is no known cause of infertility identified in the evaluation of an infertile couple, then it is
termed unexplained infertility. This occurs in 5% to 10% of couples trying to conceive. It is more
common in males than females for unknown reasons
Unexplained & combination- accounts for 20- 35% of all fertility problems

1. Unexplained It is when doctors can’t find

infertility a cause for infertility after a
full series of test &
assessments.

2. Combination The term used to describe

infertility couples who have both male
& female infertility
CLINICAL MANIFESTATIONS:

The main symptom of infertility is not getting pregnant.

Infertility Symptoms in Women

In women, changes in the menstrual cycle and ovulation may be a symptom of a disease related to
infertility. Symptoms include:

 Abnormal periods: Bleeding is heavier or lighter than usual.

 Irregular periods: The number of days in between each period varies each month.
 No periods: You have never had a period, or periods suddenly stop.
 Painful periods: Back pain, pelvic pain, and cramping may happen.

Sometimes, female infertility is related to a hormone problem. In this case, symptoms can also
include:

 Skin changes, including more acne

 Changes in sex drive and desire
 Dark hair growth on the lips, chest, and chin
 Loss of hair or thinning hair
 Weight gain

Other symptoms include:

 Milky white discharge from nipples unrelated to breastfeeding

 Pain during sex

Infertility Symptoms in Men

Infertility symptoms in men can be vague. They may go unnoticed until a man tries to have a baby.

Symptoms depend on what is causing the infertility. They can include:

 Changes in hair growth

 Changes in sexual desire
 Pain, lump, or swelling in the testicles
 Problems with erections and ejaculation
 Small, firm testicles
DIAGNOSTIC EVALUATION:

OBJECTIVES OF INVESTIGATION

1. To detect the etiological factors

2. To rectify the abnormality in an attempt to improve
3. To give assurance with explanation to the couple if no abnomality is detected.

FOR FEMALE:

INITIAL APPROACH:

HISTORY:

1. PERSONAL AND LIFESTYLE HISTORY including age, occupation, exercise, stress,

dieting/changes in weight, smoking, and alcohol use, Duration of marriage all of which can
affect fertility.
2. DURATION OF INFERTILITY and results of previous evaluation and therapy.

3. MEDICAL, SURGICAL, AND GYNECOLOGICAL HISTORY (including sexually

transmitted infections, pelvic inflammatory disease, and treatment of abnormal Pap smears) to
look for conditions, procedures, or medications potentially associated with infertility.
Obstetrical history to assess for events potentially associated with subsequent infertility or
adverse outcome in a future pregnancy.
4. MENSTRUAL HISTORY (cycle length and characteristics), which helps in determining
ovulatory status. For example, regular monthly cycles with molimina (breast tenderness,
ovulatory pain, bloating) suggest the patient is ovulatory and characteristics such as severe
dysmenorrhea suggest endometriosis.
5. PREVIOUS OBSTETRICS HISTORY:

Number of pregnancies, interval between pregnancy( in case of secondary infertility)

6. CONTRACEPTIVE PRACTICES: IUCD which may produce PID.

Sexual problemsà Dyspareunia, Loss of libido.

7. SEXUAL HISTORY, including sexual dysfunction and frequency of coitus. Infrequent or

ineffective coitus can be an explanation for infertility.
8. FAMILY HISTORY, including family members with infertility, birth defects, genetic
mutations, or mental retardation.

PHYSICAL EXAMINATION:

1. General examination:
- Obesity or marked reduction of weight
 - Abnormal distribution of hair or underdevelopment of secondary sex characters.
2. Systemic examination:
- Hypertension
- Organic heart disease
- Chronic renal lesions
- Genital tuberculosis
3. Gynecological examination:
- Adequacy of hymenal opening
- Evidence of vaginal infections
- Undue elongation of cervix
- Uterine size or position and Mobility
- Unilateral or bilateral mass
- Presence of nodules in the external genitalia.
4. Speculum examination:
- Abnormal cervical discharge

INVESTIGATIONS:

1. PELVIC ULTRASOUND: To study egg follicle development.

2. HYSTEROSALPINGOGRAM (through the vagina): To check the uterus & fallopian tube
for sign of damage or structural problem
A doctor or technician places a slender catheter inside cervix. It releases a
liquid contrast material that flows into uterus. The dye traces the shape of
uterine cavity and fallopian tubes and makes them visible on X-ray images.
Generally there is no special preparation needed for this test. However, depending
upon your diagnosis, you may need to take antibiotics to guard against possible
infection. To ensure that you are not pregnant, the study is done between Day 7 and
10 of your cycle. Prior to the procedure you may take an anti-inflammatory medication
(Aleve or Motrin). A small catheter is placed into the cervix and the dye is injected.
You may feel heavy cramping during, and for several hours following this procedure.
Expect a sticky vaginal discharge for a few days as the dye is expelled from the
uterus. Use a pad or panty liner during this time to allow fluid to escape. Any dye that
remains will be absorbed without any ill effect.
3. LAPROSCOPY (through an abdominal incision): To look for & possibly repair conditions
such as uterine fibroids, pelvic inflammatory disease or endometriosis that can prevent
pregnancy.

OTHERS:

4. INSUFFLATION TEST (RUBIN’S TEST): This is an operation of dilatation of the cervix

and introduction of air or CO2 into the uterine cavity to know the patency of the fallopian
tubes.
 5. SONOHYSTEROSALPINOGRAPHY (HSG): Normal saline is pushed within the uterine
cavity with a pediatric Foley catheter. The catheter balloon is inflated at the level of the cervix
to prevent fluid leak. Ultrasonography of the fallopian tube and uterus are done.
6. POSTCOITAL TEST ( SIMS HUHNER TEST): The patient should report to the clinic
preferably within 8-12 hours following intercourse. The cervix is exposed with a cusco’s
speculum. Using a polythene catheter attached to a syringe, the endocervical mucus is collected
& placed over a warm glass slide. A coverslip is placed over it & examined microscopically.

FOR MEN:

INITIAL APPROACH:

HISTORY:

 A review of past medical history, prior surgeries and medications used

 duration of marriage
 history of previous marriage
 A discussion of family history of infertility or birth defects
 A careful review of social history and occupational hazards to evaluate potential exposure to
hazardous substances that could impact fertility
 Mumps orchitis after puberty
 Diabetes
 Recurrent chest infections or bronchiectasis
 Relevant surgery such as hernioraphy, operation on testes or other surgery in the genital area.
 Enquire about sexual history frequency of intercourse, full penetration of penis inside vagina.
 Whether either partner experiencing discomfort.
 Lack of satisfaction.
 Social habitsà smoking , alcohol are of importance
 PHYSICAL EXAMINATION:

 A full physical examination to determine the general state of health.

 Examination of the reproductive systemà inspection & palpation of the genitalia

 Attention to be paid to the size and consistency of the testicles.

Through inspection & palpation to evaluate the pelvic organs — the penis, testes, prostate and
scrotum.
INVESTIGATION:

1. SEMEN ANALYSIS: It is done to check the amount & qulaity of semen & sperm & for signs
of infection. Semen is generally obtained by masturbating and ejaculating into a special
container. Semen is then sent to a laboratory to measure the number of sperm present and look
for any abnormalities in the shape (morphology) and movement (motility) of the sperm. The
coitus should be avoided 2-3 days prior to the test.
2. TRANSRECTAL ULTRASOUND: It is done to visualize the seminal vesicles, prostrate &
ejaculatory ducts obstruction.
3. VASOGRAM: It is a radiographic study done to evaluate the ejaculatory duct obstruction.
4. IMMUNOLOGICAL TESTS: Presence of sperm antibodies (sperm immobilizing) in the
cervical mucus is demonstrated by post coital test( PCT is to assess the quality of cervical
mucus & the ability of sperm to survive in it).
5. KARYOTYPE ANALYSIS: this is done in cases with azoospermia or severe oligospermia
and raised FSH. Klienfelter syndrome (xxy) is the commonest.

HORMONAL TEST FOR BOTH MALE & FEMALE:

1. LUTENIZING HORMONE (LH): Abnormal LH level can be a sign of female ovulation

problems or male testosterone production problem.
2. PROGESTRONE: Low progestrone levels can be a sign of ovulation problems.
3. FOLLICLE STIMULATING HORMONE (FSH): High FSH level may be a sign of low
egg supply & can prevent ovulation or in men sperm production.
4. THYROID STIMULATING HORMONE (TSH): Abnormal thyroid function can affect the
emnstrual cycle & ovulation.
5. PROLACTIN: High prolactin can be a sign of a pituitary problem which can affect ovulation.
6. TESTOSTERONE: Low testosterone in men can cause sperm production problem. High
levels in women can cause irregular menstrual periods.

TESTS LEARNING OUTCOMES

1. Is infertility more common in women or men?
Answer
Both men and women are affected by infertility: about 40–60% of causes are linked to female factors
and 20–40% are related to male factors.

2. List two types of infertility and explain the meaning of each type.
Answer
Primary infertility is when the couple have never had children, or have been unable to achieve
pregnancy after one year of living together and having unprotected sexual intercourse.
Secondary infertility is when a couple who already have children, or have achieved pregnancy
previously, are unable to conceive after one year of having unprotected sexual intercourse.
 3. Mr. X comes to you and tells you he has married three wives, but had no children yet.
When you take his medical history from him, you find out he had mumps during late
adolescence.
What are your initial thoughts about his problem?
Answer
1. Mr. X may have a primary infertility problem, possibly caused by mumps, which could have caused his
testes to become shrunken and so fail to produce normal sperm.
2. Explain that the mumps infection may have caused damage to his testes, where sperm are produced.
As a result, it is possible he may not be able to fertilise the women’s eggs.
3. Tell him as gently as you can that you will be referring him to the hospital/health centre for tests.

Summary of the causes of primary and secondary infertility in men and women
 The woman does not ovulate (produce an egg).

 The egg does not reach the correct location for fertilization because the fallopian tube(s) are
blocked.

 The man produces insufficient or abnormal sperm.

 The sperm cannot reach the egg because the spermatic tube is blocked.
CONCLUSION
Infertility is a topical problem in gynecology, which requires delicate approach, analysis and treatment.
And as a nurse we should always support the client , give them information regarding various technological
development make them aware of ethical and legal issues in the treatment.
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 Datta. D.C.(2004)Text book of Gynaecology(ed.6th) Calcutta.Dawn Book’
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Jaypee Brothers.
 Dawn C.S.(2004)Text book of obstetrics, Neonatology and Reproductive and child health
education.(ed-16th)Calcutta Dawn Book

 Kumari .Neelam (2010), Midwifery and gynecological nursing , (ed.1st),S.Vikas and

Company,medical publisher.

 Fraser.Diane.M(2009). Myles text book of midwifes (ed.15th),china, chuchill livingstone

 Rao Kumari .(2011).Text book of midwifery and obstetrics of nurses (ed.1st)New

Delhi ,Elsrvier.
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 http://www.cdc.gov/art/
 http://emedicine.medscape.com/article/263907-overview#a11
 http://en.wikipedia.org/wiki/Assisted_reproductive_technology
 http://www.slideshare.net/cjrw2/ethicsoffertilitytreatments

 http://www.uic.edu/depts/mcam/ethics/arts.htm