Chapter 7: Nursing Care of the Family Structure and function of a Sperm

having difficulty conceiving a Child  A normal sperm will have the following
215-3.5 DIAMETER
characteristics:
4.0-55 LEMGR

Structure of an Ovum o A smooth oval head

 The head of the sperm measures 2.5
Nucleus 2) EGG
OF CEL to 3.5 um In diameter and 4.0 to 5.5
o The nucleus is the heart of the egg cell; um in length (um=micrometers).
-

CHROMOSOMES o It contains most of the genetic material in

GEMERC->
-
the form of chromosomes. o They have a well-developed acrosome that
o This is where the genes are situated. covers 40 to 70 percent of the oval shaped
CHROMOSOMES o An egg, like a sperm, contains half the
=

head ACROSOME 40-70% (HEAD)

Exce
COVERS

number of - chromosomes as a normal cell,

i.e. 23 each. o A slim middle section (body) that is
approximately the same length as the head
Cytoplasm -> CELL
(ALIVE, FUNCTIONING)
ACTIVIRES

ORGAMELE -> InTERRAL

STRUCTURE
o a gel like substance that holds all the cell’s o A thinner tail section that is about 45
-

-> GEL LIKE

other internal structures, called organelles.
e n
micrometer in length TAIL:45 MICROMETER

o in the cytoplasm, that all the cell’s activities

take place to keep it alive and functioning
properly.
MITCHONDRIA-> EMERGT o Amongst the more important organelles are
FOR CELL

structures called mitochondria , which supply

most of the energy for the cell

Zona Pellicuda -> (EGG)

MEMBRARE OUTER

it
↑
ENTER(EGG)
o The zona pellucida (or egg wall) is an outer
membrane of the egg.
o This structure helps the sperm to enter the
HAR
e

FM
-

egg through itsE

hard outer layers.

& (2/3 LATER)

-> CORONA RADIAT

Corona Radiata Ex
o The corona radiata surrounds an egg and
consists of two or three layers of cells from
the follicle.
-

o They are attached to the zona pellucida the

outer protective layer of the egg and their The Sperm Head
main purpose is to supply vital proteins to 1. Nucleus
the cell.  Contains 23 chromosomes
2. Acrosome
 Involved in the recognition of the oocyte
(chemotaxis)
 Contains:
o Hyaluronidase PERERRATES ENEYME
 Corona penetrating
enzyme
o Acrosin DIGESTS IP

 Digests the zona pellucida

 Midpiece Motility A. H
 contains tightly packed mitochondria that provide - 2 types of physiological motility
the energy requires for swimming. 1. Activated Motility EPI, ETA
EARLY STAGE
*  This is the type observed in the early
GENTLE
*
MOVEMENT,
stages of motility (in the epididymis
IN STRAIGHT PAN as well as freshly ejaculated sperm).
 Gentle movement of the sperm's
flagella from one side to another as
the cell moves along what may
appear to be a straight path.

2. Hyperactivated motility (hyperactivation)

OCCURS
* IN  this type of motility occurs is in the
FEMALE female reproductive tract (site of
Centriole PART OFTHESPERM CELL
MORE ERARC fertilization).
 The centriole is part of the sperm cell located *

 Movement is more erratic and more

between the> head and theX midpiece PREVENT
* SC
-

FROM RRAP energy is used for movement.

 Essential for movement of the pronuclear for
 serves to prevent the sperm cell from
union with the female genome.
getting trapped, propelling through
the reproductive tract (of the female)
as well as enhancing sperm
penetration into the egg (oocyte).

Infertility

 is a term used to describe the inability to conceive

Tail (Flagellum) C, M, P, E a child or sustain a pregnancy to birth.
 A couple is said to be infertile if they have not
 It is divided into several parts that include:
become pregnant after at least 1 year of
1. Connecting piece unprotected coitus.
o This is the part that connects the
FLAGELLVM
SPERM
=>

flagellum to the sperm head

-
Subfertility

2. Midpiece (MITOCHONDRIAWEMERGY(  term used rather than “infertility” because it

o It contains mitochondria and thus denotes that couple has a potential to conceive
provided the energy required for
“Affects 8% to 12% of couples desiring children”
movement

3. Principal piece (axial filament) Subfertility

4. End piece Subfertility
 Is a lessened ability to conceive

Primary subfertility
 There have been no previous
conceptions.
Secondary subfertility
 There has been a previous viable
pregnancy but the couple is unable to
conceive at present because of a known
-condition.
 Sterility the activity of insulin.
 inability to conceive due to known cause such as
-
 The body can also become resistant to
absence of a uterus insulin. This can lead to diabetes
 is the inability to create offspring (children) as a result
of a procedure such as tubal ligation, hysterectomy, 2. Effect on Circulatory Problems
or vasectomy. TUB L, HYSE / VASE  Cardiovascular diseases due to stress induced
 Tubal Ligation FEMALE mechanisms are mediated primarily through
 Also known as “getting your tubes tied,” is a increased adrenergic stimulation.
FALLOPIAN TBE procedure in which a woman’s fallopian  Both adrenaline and cortisol (increased during
BLOCKE /
ARE
tubes are blocked or partially removed, stress) affect heart and blood pressure.
REMOVES
preventing the chance for sperm and eggs T Too much adrenaline makes blood pressure to go

BLOOD PRESSURE

to meet. FT (SPERM MEET)+ EGG:

 Vasectomy MALE
 is similar to a tubal ligation, but for males
the tube that allows sperm to travel out
from the testicle is partially removed.
 up which in turn affects the functioning of the
heart since the heart has to pump harder and
faster
 Cortisol also alters bone mineral density thus
affecting the development of new bones in the
body.

 Some women also experience sterility as a result 3. Suppression of Immune System

of a hysterectomy, or removal of the uterus.
Predisposing Factors: Subfertility
1. Age often increases the risk of infertility.
2. Infertility can be caused by poor sexual or lifestyle
habits that are easily remedied…
AGE, POOR SEXUAL A LIFESTYLE
 The high levels of stress hormones suppress the
release of cytokines chemicals secreted by Th
cells (T helper cells a type of T lymphocytes).
 Cytokines regulate both cell mediated and
humoral immune response in the body

For example: 4. Stress also interferes with Reproductive System both

 the couple may be using a sexual lubricant that
interferes with the survival of the man's sperm.
Infertility
Predisposing Factors: Infertility
1. Infertility can be caused by poor sexual or lifestyle
habits that are easily remedied.
 they may not be having sex often enough.
 Heavy use of alcohol, tobacco or drugs. A, T, D
- - -
in men and women
 Chronic stress may decrease libido and may even
cause erectile dysfunction or impotence in man
 Testosterone levels can drop to an extent that can
interfere spermatogenesis (sperm production).
 In women, stress can affect menstrual cycle.
 It can lead to irregular, heavier or more painful
periods.

 Starvation diets or anorexia in the woman. Nursing Process overview for a couple with
 Tight underwear or pants in men.
 Stress: Subfertility
IRREGULAR
*
 In a woman, this may cause her periods to
PERIOD

REDUCE
*
be irregular.
SPERM
 ASSESSMENT
count
 In a man, stress may reduce his sperm o require many months and many tests, all of
count.
which had the potential to interfere with a
couple’s self-image, self-esteem, and lifestyle
Impact of Stress on the Body
1. Effect on Digestive System o Today , a subfertility investigation is usually
DEH  Disturbed eating habits limited to only three assessments:
A  acid reflux S 1. Semen analysis,
D  diarrhea or constipation 8 2. Ovulation monitoring, and
O
 Obesity which is linked to a host of other health
-

I 3. Tubal patency.
DIABETES
problems.
o Even with this more directed approach to
 Extreme stress can also be associated with
evaluation, a nursing assessment often
diabetes.
CORTISOL AFFECTS

InSULIN  This is because excessive cortisol can affect reveals that one or both partners feel
inadequate or angry and frustrated by what
 has happened to them and their need to
undergo testing.
 Nursing Dx
o focus on psychosocial issues associated with
the inability to conceive and the potentially
nerve wracking process of fertility testing and
management.
o Examples of possible diagnoses
include:
1. Fear related to possible outcome of
subfertility studies
2. Situational low self-esteem related to the
apparent inability to conceive
3. Anxiety related to what the process of
fertility testing will entail
4. Deficient knowledge related to measures
to promote fertility
5. Anticipatory grieving related to failure to
conceive or sustain a pregnancy
6. Powerlessness related to repeated
unsuccessful attempts at achieving
conception
7. Hopelessness related to perception of no
viable alternatives to usual conception
8. If required tests interfere with a couple’s
relationship (including sexual patterns),
“sexual dysfunction related to command
performance of subfertility therapy”
might be applicable.
 Expected Outcomes and Planning
o In establishing expected outcomes with a
couple undergoing fertility testing and
counseling, be certain the couple realizes
even after the reason for their subfertility
is identified, fertility may not be
instantaneous.
o In some instances, a couple may need to
change or modify their goals if tests begin
to show what they first wanted to have a
child without medical intervention is
impossible.
o Participation in a support group may
allow a couple to work through the stress
fertility testing places on their lives.
 Implementation
o Fertility testing can be costly for a couple
because not all health insurance programs
provide reimbursement for these procedures.
 be certain couples are informed
beforehand of specific estimates of
the cost of testing or therapy so they
can budget and plan their resources
and the next steps they want taken.
o It also may help provide them with time for
sharing experiences and increasing intimacy,
helping to compensate for any decreased
enjoyment that comes from “scheduled”
sexual relations.
o Throughout testing, couples need thorough
education about the various procedures being
done.
o Make sure to review any specific instructions
about pre-procedural and post-procedural
care.
o Depending on their motivations, a
couple’s reaction to study results may
vary from relief, to stoic acceptance,
to grief for children never to be born.
o Each partner may wonder whether
the other will be able to continue the
relationship if he or she turns out to
be the subfertile one.
 Outcome Evaluation
o Examples of expected outcomes in this area
include:
1. The patient rearranges work plans to manage
the schedule of fertility testing by 1 month
time.
2. The couple verbalizes they understand their
individual subfertility problem after
preliminary testing.
3. The couple demonstrates a high level of self-
esteem after fertility studies, even in the face
of disappointing study outcomes.
4. For a couple with the problem of subfertility,
an evaluation is best if it is ongoing because,
as circumstances around them change, so
may their goals and desires.
5. Until they can accept an alternative method
of having children adoption or an assisted
reproductive technique such as alternative
insemination (deposition of sperm into a
 woman’s cervix or uterus) or in vitro
fertilization (IVF; the union of sperm and
ovum under laboratory conditions) former
plans to have children have been crushed.
6. Continuing or future evaluations are also
 If your cells become resistant to the action of insulin,
then your blood sugar levels can rise and your body
might produce more insulin.
o Excess insulin might increase androgen
production, causing difficulty with ovulation.
↑
ARDROGEN DIFFICULT
=

OUULARON

important because a couple who decides at 4. Low grade inflammation.

age 20 years to choose child free living may
change their minds at a later date.
7. In the same way, a couple who chooses an
assisted reproductive technique may decide
after a number of unsuccessful attempts that
they are no longer interested in this method
of conception.
8. Keeping the evaluation as an ongoing process
allows such plans to be modified as
necessary.
 This term is used to describe white blood cells'
production of substances to fight infection.
 Research has shown that women with PCOS have a
type of low grade inflammation that stimulates
polycystic ovaries to produce androgens, which can
lead to heart and blood vessel problems.
5. Hereditary
 Research suggests that certain genes might be linked
to PCOS.

Infertility: FOR WOMEN

 Causes for female infertility are:
1. Pelvic Inflammatory Disease (PID)
 an infection of the pelvis or one or more of the
reproductive organs, including the ovaries , the
fallopian tubes , the cervix or the uterus
INFECTION:O, F, 2, 5
 stems from the same bacteria that cause sexually
transmitted diseases, such as gonorrhea or chlamydia
Symptoms Include: PCOS edition
STD:C, G
 Excessive facial hair

*
 may also develop from bacteria that reach the T  Thinning hair
reproductive organs through abortion, hysterectomy,
 Acne
childbirth, sexual intercourse, use of an intrauterine
 Depression
(IUD) contraceptive device or a ruptured appendix W 
#
Unexplained weight gain
BACTERIA:
H I
 Irregular or no periods
Si  High insulin or cholesterol readings
IWD

R
A

3. Endometriosis
IUD Inside the uterus
 Endometriosis refers to a condition in which sections of
the uterine lining implant in the vagina, ovaries, fallopian
2. Polycystic ovary syndrome (PCOS)
tubes or pelvis.
 The exact cause of PCOS isn't known.
 Factors that might play a role include:
1. In PCOS, the ovaries produce high amounts of male
hormones, especially testosterone resulting in hirsutism
and acne.
2. LH levels also remain abnormally high while FSH levels
are abnormally low; LH*; FSH 1
 thus, the follicles do not produce eggs. Instead they
form fluid filled cysts that eventually cover the
ovaries.
3. Excess insulin.
 Insulin is the hormone produced in the pancreas that  These implants eventually form cysts that grow with each
allows cells to use sugar, your body's primary energy menstrual cycle, and may eventually turn into blisters and
supply. scars.
  The scars can then block the passage of the egg. 6. Luteal Phase Detect
 In a luteal phase defect, a woman's corpus luteum (the
mound of yellow tissue produced from the egg follicle)
may fail to produce enough progesterone to thicken the
uterine lining.
 Then the fertilized egg may be⑳unable to implant.

7. Fibroids
4. Ovary Problems
 Fibroids, or benign growths, may form in the uterus near
 Decreased production of any one of the five hormones -

the fallopian tubes or cervix.

that regulate a woman's reproductive cycle may result in -

 As a result, the sperm or fertilized egg>

cannot reach the
infertility.
uterus or implant there.
 GnRH or LHRH -

 Fibroids in the uterus are very common in women over

 FSH
age 30.
 LH
 Estrogen
 Progesterone

Phase FSH (IU/L) LH (IU/L)

Early 3 -10 2 -8
follicular
Mid-cycle 4 -25 10 -75
peak
Phase Estradiol (pmol/L)
Early follicular 300 picomole/liter
Ovulatory surge 500 -3000 8. Surgical Complications
 Scar tissue (adhesions) left after abdominal surgery can
Luteal surge 100 -1400
causeE problems in the movement of the ovaries, fallopian
PROGESTERONE (nanomole/liter) tubes, and uterus, resulting in infertility.
0 –6 nmol/L ovulation unlikely  Frequent abortions may also produce infertility by
7 –25 nmol/L ovulation possible Eweakening the cervix or by leaving scar tissue that
> 25 nmol/L ovulation likely obstructs the uterus.

 Problems within the ovaries may inhibit reproduction as 9. Poor quality cervical mucus
well. Instead of releasing an egg, the ovarian follicle  Sometimes a woman's mucous fails to thin around the
remains⑧
-

empty, fails to rupture or traps the egg. time of ovulation, and consequently itCprevents the sperm
 Turner’s syndrome ( hypogonadism) from traveling through it.
e n

o No ovaries to produce ova.  A cervical infection may also be the cause.

o it results from a hormonal imbalance caused by a
condition such as hypothyroidism, which 10. Premature Menopause
interferes with hypothalamus pituitary ovarian  Some women may experience premature menopause,
interaction. HYPOTHYROIDISM HORMORAL
=

when their ovaries stop producing eggs.

IMBALARCE
 Cause:
 Ovarian tumors Excessive exercise or anorexia.

 Excessive exposure to X rays or radioactive substances

Infertility: FOR MEN
5. Immune System Problems
 The most common cause for male infertility is a
 Women may develop antibodies or immune cells that
-

problem with the sperm eitherE low sperm count or

C
attack the man's sperm, mistaking it for a toxic invader.
sperm with poor quality.
 Certain autoimmune diseases, in which the woman's
 Some conditions that may contribute to sperm
immune cells attack normal cells in her own body, may
problems include:
alsoEcontribute to ovarian problems.
1. Under-developed testes
 usually arising after a mumps infection, a hernia
surgery, an injury or birth defect.
2. Swollen veins in the scrotum
3. Undescended testes (cryptorchidism)
 a problem often present from birth in which the
testes remain in the body cavity.
 Normally, they descend into the scrotum before birth.
-
4. Infections
 such as gonorrhea or tuberculosis
 block the ducts through which the sperm travel
-
5. Exposure to metals
 such as leads, or chemicals such as pesticides
6. Certain medications
 such as Tagamet (cimetidine), Dilantin (phenytoin),
- -
Folex (methotrexate), Axulfidine (sulfasalazine),
- -
corticosteroids and chemotherapy drugs such as
e
Cytoxan and Neosar (cyclophosphamide)
T CHEMUNERAPY DRUGS:
C To determine sperm count & motility
E N
S Average ejaculation: 2.5 - 5 ml
7. Injury to the testicles
8. Chronic prostate infections
CPI
9. Autoimmunity
 in which antibodies or cells of the man's immune
system#attack sperm cells, mistaking them for toxic
invaders.
-
 The antibodies attach
- themselves to the sperm and
may cause them to stick together, or may stop them
from penetrating the cervical mucus or the egg.
10. Retrograde ejaculation
 In retrograde ejaculation the muscles of the urethra
do not force the sperm out.
-
 Instead, the> sperm travel backward into the bladder.
-
 Causes of retrograde ejaculation include:
 Drugs such as tranquilizers or high blood
pressure medicines.
 Diseases such as diabetes or multiple sclerosis.
 Neck, bladder or prostate surgery.
 Spinal cord injury.
11. Varicocele, or Varicosity (enlargement) of the
internal spermatic vein
 can also increase temperature and congestion within
the testes, which may slow and disrupt
spermatogenesis.
↑
TEMPERATURE -
SLOW & DISRUPT
SPERMATOGENESIS
Diagnostic Tests – Male
Semen Analysis
Must have 2 4 days of sexual abstinence prior to the
test.
Average normal sperm count: 50 200 million/ml
The minimum sperm count considered normal has:
 33 46 million sperm/ml of seminal fluid, or 50
million per ejaculation
 Fifty percent (50%) of sperm that are motile
 Thirty percent (30%) that are normal in shape
and form
Tips for ensuring an accurate Semen Analysis
1. Abstain from intercourse or masturbation for about 2
to 4 days. & INTERCOURSE / MASNRBARON (2-4)
2. Use a clean, dry plastic or glass container with a
secure lid to collect the sample.
3. Avoid using any lubricants before you collect the
specimen.
4. After you’ve collected the specimen in the container,
close it securely and write down the time you
collected it.
5. Take the specimen to the laboratory or healthcare
provider’s office immediately so it can be analyzed
within 1 hour of collection.
6. Keep the specimen at body temperature while for three days or more.
transporting it. Carrying itC
next to your chest is one
way to do this. 3. Plan sex carefully during fertile days.
You're most fertile about two days before your
basal body temperature rises, but sperm can
Diagnostic Tests – Male : Additional testing for men, if live up to five days in your reproductive tract.
warranted, can include: If you're hoping to get pregnant, this is the
 urinalysis time to have sex.
 a complete blood count (CBC)
 blood typing, including Rh factor
 a serologic test for syphilis; a test for the presence of
- -

DHIV
 Erythrocyte sedimentation rate (an increased rate
indicates inflammation)

 Protein bound iodine (a test for thyroid function)

-

Hypothyroidism can cause poor semen quality,

low sperm count, reduced testicular function,
dysfunction, and drop in libido.

 cholesterol level (arterial plaques could interfere with

pelvic blood flow)

 Follicle stimulating hormone (FSH), luteinizing

hormone (LH), and testosterone levels

Diagnostic Tests - Female

1. Basal Body Temperature (BBT)
 a fertility awareness based method is a type of
natural family planning
 By tracking your basal body temp. each day, you may
be able to predict when you'll ovulate.
 In turn, this may help you determine when you're
most likely to conceive.
 If you're hoping to get pregnant, you can use the BBT
method to determine the best days to have sex.

How to use BBT method

1. Take your BBT every morning before getting out
of bed.
Use a digital oral thermometer or one
specifically designed to measure BBT.
Make sure you get at least three hours of
uninterrupted sleep each night to ensure an
accurate reading.
Always take your temperature using the same
method.

2. Plot your temperature readings on graph paper.

Record your daily basal body temperature and
look for a pattern to emerge.
Your BBT may increase slightly typically less
than a 1/2 degree F (0.3 C) when you ovulate.
You can assume ovulation has occurred when
the slightly higher temperature remains steady
 Diagnostic Tests - Female
2. Cervical Mucus Exam
 To determine elasticity for sperm motility
 SPINNBARKEIT
 Once you notice that your CM has the consistency of
raw egg whites, you know you're in your fertile
period.
 If you hold it between two fingers, it can stretch an
inch or two without breaking in the middle.
 This type of CM allows the sperm to swim easily into
the cervix.
3. Pelvic Exam & Ultrasonography
 To identify obvious reproductive problems
4. Blood hormone levels & thyroid function test
 To measure levels of estrogen & progesterone, and
influence of thyroid hormones
5. Sims-Huhner Test (Post coital cervical mucus test)
 To determine pH of cervical mucus, effects of
hormones.
6. Tubal patency Test
 Hysterosalpingogram (X ray)
 Laparoscopic exam (direct visualization)
 To determine condition and patency of
fallopian tubes
7. Endometrial Biopsy
 To determine condition of endometrium
8. Hysteroscopy
 Visual inspection of the uterus through insertion of
hysteroscope through the vagina, cervix, and into the
uterus
Nursing Implications
1. Take careful lifestyle and sexual history of both
partners, chronic health problems, medications,
smoking, drug use, exposure to chemicals, radiation.
2. Provide detailed explanation of all tests to couple.
3. Know that process of assessment of fertility and
subsequent interventions may be lengthy
Interventions
1. Therapy for Anovulation
 Important for adequate ova production:
1. Nutrition
2. Body weight
3. Exercise
 are all important for adequate ova production
because they all influence the blood
glucose/insulin balance
 Therapy for Anovulation
1. Nutrition
 High glucose or insulin levels
 can disrupt the production of FSH and LH,
leading to ovulation failure

 Vitamin D
 may also be instrumental in maintaining
pituitary hormone levels

2. Body Weight
 Maintain a BMI of 18.5 to 24.9.
 Eat slowly digested carbohydrate foods (e.g., brown
rice, pasta, dark bread, beans) and fiber rich
vegetables (e.g., asparagus, broccoli)
 can not only increase fertility by keeping
insulin levels balanced but also may prevent
gestational diabetes when a woman
becomes pregnant

3. Exercise
 Exercising 30 minutes per day by walking or doing
mild aerobics also helps to regulate blood glucose
levels and increase fertility,
 Stress may play a role in limiting ovulation
as this may lower hypothalamic secretion of
the gonadotropin releasing hormone ( GnRH
), which then lowers the production of LH
and FSH, which leads to anovulation.
 Drugs that affect Gonadal function & Fertility
 Androgens schedule and also to determine and plot
 To replace deficient male hormones ovulation.
 Remind patients that timing intercourse
with ovulation is important for achieving
 Estrogens
pregnancy.
 To replace deficient hormones to control  Advise patients 24 hour urine samples may
hormonal balance be periodically necessary.
 Caution patients to report any bloating,
 Conception Enhancers stomach pain, blurred vision, unusual
bleeding, bruising, or visual changes.
 Ovulatory stimulants
 Inform patients that therapy can be
o Clomiphene Citrate (Clomid) repeated for a total of three courses; if no
 A follicle-stimulating agents results are obtained, therapy will be
used during the 5th – 10th day discontinued at that point.
of menstrual cycle.
Clomiphene Citrate (Clomid)
Action: o Bromocriptine (Parlodel)
 Clomiphene citrate (Clomid ) is an estrogen  Inhibits release of prolactin
agonist commonly used to stimulate the which can cause unovulation
ovary.
o Human Menopausal Gonadotropin
(Pergonal)
Dosage:
 Acts similarly to FSH or LH to
 Initially , 50 mg/day orally for 5 days
(started anytime if no menstrual flow has stimulate growth and
occurred recently or about the fifth day of maturation of ovarian
the cycle if menstrual flow is occurring). follicles
 If ovulation does not occur with this initial
therapy, the drug can be followed by a o Gonadotropin-releasing hormone
prescription of 100 mg/day for 5 days
(GnRH)
started as early as 30 days after the initial
 Used when clomiphene is
course of therapy.
 This second course may be repeated one ineffective
more time.
 For hyperplasia defects:
Possible Adverse Effects: o Danazol (Cyclomen)
 Abdominal discomfort  Reduces endometrial
 Distention
hyperplasia
 Bloating
 Nausea & vomiting  Inhibits estrogen defects
 Breast tenderness
 Vasomotor flushing o Prednisone
 Ovarian enlargement  Reduces adrenal hyperplasia
 Ovarian overstimulation
 Multiple births
 Visual disturbances Therapy for lack of Tubal Patency
1. Diathermy or steroid administration may be helpful to
Nursing Implications: reduce adhesions
 Ensure women have had a pelvic 2. Hysterosalpingography (instillation of a contrast dye
examination and baseline hormonal studies
under X ray monitoring) can be attempted to see if
before therapy.
 Review medication scheduling. the force of the dye insertion will break adhesions.
 Urge women to use a calendar or some 3. Canalization of the fallopian tubes and plastic surgical
other system to mark their treatment repair (microsurgery) are other possible treatments.
4. Laparoscopy or laser surgery
 To remove peritoneal adhesions or nodules of
endometriosis that are holding the tubes
fixed and away from the ovaries.
5. IVF is more commonly used today and more apt to
result in a viable pregnancy.
Assisted Reproductive Techniques
 If ovulation, sperm production, or sperm motility
problems cannot be corrected, assisted reproductive
strategies are the next step.
1. Therapeutic Insemination
 Alternative or IUI is the instillation of sperm
from a masturbatory sample into the female
reproductive tract by means of a cannula to
aid conception at the time of ovulation
2. IVF
3. Gamete Intrafallopian transfer (GIFT)
4. Zygote intrafallopian transfer (ZIFT)
5. Surrogate embryo transfer
Therapy for increasing Sperm Count and Motility
1. Abstain from coitus for 7 to 10 days at a time to
increase the count.
2. Ligation of a varicocele (if present)
3. Avoid recreational marijuana use
4. Wear looser clothing
5. Avoid long periods of sitting, and
6. Avoid prolonged hot baths
Therapy for Sperm Transport Disorders
1. If sperm are not able to pass through the vas deferens
because of obstruction, surgery to relieve the
obstruction is extensive, costly, and may not have a
positive outcome.
A better solution can be extracting sperm from a
point above the blockage and injecting it into the
vagina or uterus of the man’s partner by
intrauterine insemination (IUI)
Today, sperm can be cryopreserved (frozen) in a
sperm bank before radiation or chemotherapy
and then used for alternative insemination
afterward
2. If the problem appears to be that sperm are
immobilized by vaginal secretions due to an
immunologic factor
 The response can be reduced by abstinence or
condom use for about 6 months
 The administration of corticosteroids to a
woman may have some effect in decreasing
sperm immobilization because it reduces her
immune response and antibody production.
Therapy for Ejaculation Concerns
1. Psychological or sexual counseling
2. Use of a phosphodiesterase inhibitor, such as
sildenafil ( Viagra ) or tadalafil (Cialis )
3. Dapoxetine , a short acting selective serotonin
reuptake inhibitor, is a drug that has been developed
especially for the treatment of premature ejaculation
and shows good results when taken about 1 hour
before planned coitus
Therapy for Uterine Concerns
1. Luteal phase defect
 this can be corrected by progesterone vaginal
suppositories begun on the third day of a
woman’s temperature rise and continued for
the next 6 weeks (if pregnancy occurs) or until
a menstrual flow begins.
2. Myoma (Fibroid tumor) or Intrauterine adhesions
 a myomectomy, or surgical removal of the
tumor and adhesions, can be scheduled
 If the growth is small, this can be done by a
hysteroscopic ambulatory procedure.
 The woman may be prescribed estrogen for 3
months as another method to prevent
adhesion formation.
 An intrauterine device (IUD) may be inserted
to prevent the uterus from touching and
forming new adhesions;
o Be certain she has a good explanation
of the IUD’s purpose and that it can
be easily removed in about 1 month
time.
3. Abnormal uterine formation, such as a Septate
Uterus
 Surgery is also available. However, these
defects are usually related to early pregnancy
loss, not initial subfertility
4. Endometriosis
 can be treated both medically and surgically;
Treatment: Endometriosis
1. Pain Medication
 Nonsteroidal anti inflammatory drugs
(NSAIDs) ibuprofen (Advil, Motrin IB, others)
or naproxen sodium (Aleve) to help ease
painful menstrual cramps
2. Hormone Therapy
1. Hormonal Contraceptives
 Birth control pills, patches and vaginal
rings help control the hormones
responsible for the buildup of
endometrial tissue each month.
 Using hormonal contraceptives
especially continuous cycle regimens
may reduce or eliminate pain in some
cases.
2. Gonadotropin-releasing hormone (Gn-RH)
agonists and antaonists
 These drugs block the production of
ovarian stimulating hormones,
lowering estrogen levels and
preventing menstruation.
 This causes endometrial tissue to
shrink.
 Because these drugs create an
artificial menopause, taking a low
dose of estrogen or progestin along
with Gn-RH agonists and antagonists
may decrease menopausal side
effects, such as hot flashes, vaginal
dryness and bone loss.
 Menstrual periods and the ability to
get pregnant return when you stop
taking the medication.
Therapy for Vaginal and Cervical Concerns
1. If sperm do not appear to survive in vaginal
secretions because secretions are too scant or
tenacious
 a woman may be prescribed low dose
estrogen therapy to increase mucus
production during days 5 to 10 of her cycle.
 Conjugated estrogen ( Premarin ) is a type of
estrogen prescribed for this purpose.
2. If a vaginal infection is present
 the infection will be treated according to the
causative organism based on culture reports.
 Vaginal infections such as trichomoniasis and
moniliasis tend to recur, requiring close
supervision and follow up.
 If the woman’s sexual partner is the source of
infection, and is therefore reinfecting her, the
partner needs antibiotic therapy as well.
3. Caution women who are prescribed metronidazole (
Flagyl ) for a Trichomonas infection;
 Although no studies have shown fetal
malformations after its use, it may be
teratogenic early in pregnancy and therefore
should not be continued if the woman
suspects she has become pregnant.
Unexplained Subfertility
It is obviously discouraging for couples to complete a
fertility evaluation and be told their inability to
conceive cannot be explained.
Offer active support to help the couple find
alternative solutions at this point, such as continuing
to try to conceive, using an assisted reproductive
technique, choosing to adopt, or agreeing to a child
free life.
Assisted Reproductive Techniques
 If ovulation, sperm production, or sperm mobility
problems cannot be corrected, assisted reproductive
strategies are the next step for a couple to consider.
 Before beginning any of these procedures:
1. Urge a woman to be in excellent health by
discontinuing smoking or recreational drug
behaviors
2. Ingesting a diet high in protein
 3. A BMI within a normal range of 18.5 to 24.9.
4. Tests for HIV and hepatitis C
5. A hormone profile including levels of FSH, LH,
estrogen, and progesterone to test for ovarian
reserves (whether ovaries have the capacity to
produce multiple oocytes)
6. Intravaginal sonogram to visual usual structures.
7. Consider the budget
8. Availability of health insurance because the
couple may not be able to afford these therapies
9. Consider their religion or cultural beliefs because
they may find these unacceptable procedures.
LGBT couples may also feel uncomfortable
seeking reproductive advice.
10. In all instances, culturally sensitive care is
required by the nurse
Assisted Reproductive Techniques
A. Alternative Insemination (IUI)
 Alternative or IUI (Intrauterine Insemination)is the
instillation of sperm from a masturbatory sample into
the female reproductive tract by means of a cannula
to aid conception at the time of ovulation
 The sperm can either be instilled into the cervix
(intracervical insemination) or directly into the uterus
(IUI) at the time of predicted ovulation.
 BBT charting, mucus analysis, or urinary test
kits for LH can be used to detect the day of
ovulation
 Either the male partner’s sperm (alternative
insemination by male partner) or donor sperm
(alternative insemination by donor) can be used.
Indications:
1. The male partner has no sperm or an inadequate
sperm count
2. A woman has a vaginal or cervical factor that
interferes with sperm motility
3. A woman has hormonal issues affecting fertility.
4. Donor insemination can be used if the man has a
known genetic disorder he does not want to be
transmitted to children
5. A woman does not have a male partner.
6. It is also a useful procedure for men who underwent a
vasectomy but now wish to have children.
 Today , sperm can be cryopreserved (frozen) in a
sperm bank before radiation or chemotherapy and
then used for alternative insemination afterward
Preparation:
 A woman receives an injection of clomiphene
(Clomid) or FSH 1 month prior to the insemination
 so follicle growth of ova is stimulated
 ovulation can be predicted.
Procedure:
1. On the selected day of insemination (confirmed by a
serum analysis of progesterone), the sperm sample is
instilled next to her cervix using a device similar to a
cervical cap or diaphragm, or sperm are injected
directly into the uterus using a flexible catheter.
2. Donors for alternative insemination are volunteers
who have no history of disease and no family history
of possible inheritable disorders.
3. The blood type, or at least the Rh factor, can be
matched with the woman’s to prevent
incompatibility.
4. Sperm can be selected according to desired physical
or mental characteristics if desired.
5. If FSH was used to stimulate follicle growth, caution
women that the chance for a multiple birth (twins or
triplets) increases so she can be prepared for this
B. In Vitro Fertilization (IVF)
Indications:
1. Woman has obstructed or damaged fallopian tubes
2. Man has oligospermia or a very low sperm count.
3. Absence of cervical mucus prevents sperm from
entering the cervix or antisperm antibodies cause
immobilization of sperm
4. Couples with unexplained subfertility of long duration
Preparation:
1. 1 month before the procedure, the woman is given
FSH to stimulate oocyte growth.
2. Beginning about the 10th day of the menstrual cycle,
the ovaries are examined daily by sonography to
assess the number and size of developing ovarian
follicles.
3. When a follicle appears to be mature, a woman is
given an injection of hCG, which causes ovulation in
38 to 42 hours.
Procedure:
1. One or more mature oocytes are removed from a
woman’s ovary by laparoscopy and fertilized by
exposure to sperm in a laboratory.
2. The oocytes chosen are incubated for at least 8 hours
to ensure viability.
3. The male partner or donor supplies a fresh or frozen
semen specimen.
4. A donor ovum, rather than the woman’s own ovum,
can be used for a woman who does not ovulate or
 who carries a sex linked disease she does not want to
pass on to her children.
5. Young women who had extensive ovarian radiation or
ovaries removed before surgery for ovarian cancer
can have oocytes cryopreserved before surgery and
used for IVF
6. The sperm cells and oocytes are mixed and allowed to
incubate in a growth medium.
7. About 40 hours after fertilization, the laboratory
grown fertilized ova (now zygotes) are inserted into a
woman’s uterus, where, ideally, one or more of them
will implant and grow.
8. Genetic analysis to reveal chromosomal abnormalities
or the potential sex can be completed at this point.
9. Progesterone or LH may be prescribed to a woman
following IVF
10. A routine serum pregnancy test as early as 11 days
after transfer will be done
 Proof that zygote has implanted
Overall Live Birth Rate by IVF:
 41 % to 43% per treatment cycle for women under 35
years
 It is as low as 13% to 18% for woman age 40 years
(American Pregnancy Association, 2015).
 About 25% of pregnancies end in spontaneous
miscarriage (the same rate as for natural pregnancies
 COST: $12,000 to $17,000 per cycle
C. Gamete Intrafallopian Transfer
 In gamete intrafallopian transfer (GIFT) procedures,
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.
D. Zygote Intrafallopian Transfer
 Zygote intrafallopian transfer (ZIFT) is similar to IVF in
that the egg is fertilized in the laboratory,
 The fertilized egg is transferred by laparoscopic
technique into the end of a waiting fallopian tube.
E. Surrogate Embryo Transfer
 Surrogate embryo transfer is an assisted reproductive
technique for a woman who does not produce ova.
Procedure:
1. The oocyte is donated by a friend, relative, or an
anonymous donor
2. The menstrual cycles of the donor and recipient are
synchronized by administration of gonadotropic
hormones.
3. At the time of ovulation, the donor’s ovum is
removed by a transvaginal, ultrasound guided
procedure.
4. The oocyte is then fertilized in the laboratory by the
recipient woman’s partner’s sperm (or donor sperm)
and placed in the recipient woman’s uterus by
embryonic transfer.
5. Once pregnancy occurs, it progresses the same as an
unassisted pregnancy.
Alternatives to Childbirth
1. Surrogate Mothers
A surrogate mother is a woman who agrees to
carry a pregnancy to term for a subfertile
couple or an LGBT couple
The surrogate may provide the ova, which is
then impregnated by the man’s sperm in the
laboratory.
In other instances, the ova and sperm both
may be donated by the subfertile couple; in a
third technique, both donor ova and sperm
are used.
Surrogate mothers 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.
The subfertile couple can enjoy the pregnancy
as they watch it progress in the surrogate.
A number of ethical and legal problems arise
if the surrogate mother decides at the end of
pregnancy that she has formed an
attachment to the fetus and wants to keep
the baby despite the prepregnancy
agreement she signed.
 Court decisions have been split on whether
the surrogate or the subfertile couple has the
right to the child.
Another potential problem occurs if the child
is born imperfect and the subfertile couple
then no longer wants the child.
Who should have responsibility in this
instance?
For these reasons, the couple and the
surrogate mother must be certain they have
given adequate thought to the process and to
what will be the outcome should these
problems occur before they attempt
surrogate mothering.
2. Adoption
Adoption is an alternative for subfertile and
LGBT couples, those individuals who have
genetic related health conditions or health
conditions that would make pregnancy high
risk.
If a couple still wishes to include children in
their lives in some way, many opportunities
are available to do this through family
connections (most parents welcome offers
from siblings or other family members to
share in childrearing), through volunteer
organizations (such as Big Brother or Big
Sister programs), or through local schools and
town recreational programs.
 Many couples who believe overpopulation is a major
concern choose child free living even if subfertility is
not present
 Parents who choose child free living typically rate
their marriage as happier than for those with children
probably because of the decreased expense involved
and the availability of more free time, which allow
them greater freedom in life

3. Child-Free Living
Child free living is another option available to
both fertile and subfertile couples.
A couple in the midst of fertility testing may
begin to reexamine their motives for pursuing
pregnancy and may decide pregnancy and
parenting are not worth the emotional or
financial cost of future treatments.
They may decide the additional stress of
going through an adoption is not for them
either, or they may simply decide children are
not necessary for them to complete their
family unit.
Child free living can be as fulfilling as having
children because it allows a couple more time
to help other people and contribute to society
through personal accomplishments
It has advantages for a couple in that it also
allows time for both members to pursue
careers.
They can travel more or have more time and
money to pursue hobbies or continue their
education.