NURSING CARE OF A FAMILY

HAVING DIFFICULTY
CONCEIVING A CHILD
NCM 108
Fritzie Necitas A. Duran, RN
 Infertility

• Infertility is the inability to conceive after at least 1 year of sexual

intercourse at least 4 times per week without contraception.
a) Primary infertility refers to no previous history of either
partner conceiving or impregnating.
b) Secondary infertility is the inability to conceive after a previous
successful pregnancy
Factors contributing to female infertility:
• Vaginal problems include vaginal infections, anatomic
abnormalities, sexual dysfunction that prevents
penetration by the penis, a highly acidic vaginal
environment, which markedly decreases sperm survival,
and use of coital lubricants.
• Cervical problems include:
a) A disruption in any of the physiologic changes that normally occur
during the preovulatory and ovulatory period that make the cervical
environment conducive to sperm survival( such as opening of the
cervical os, increased alkalinity, increased secretions, ferning and
antisperm antibodies)
b) Mechanical problems, such as cervical incompetence associated with
women whose mothers were treated with diethylstilbestrol(DES) during
pregnancy
• Uterine problems may be:
a.) Functional such as an unfavorable environment for the
movement of sperm up to the uterus into the fallopian
tubes or for implantation after fertilization
b.) Structural such as uterine myomas or leiomyomas
• Tubal problems
a) Infertility due to tubal problems is becoming more
prominent with the increased incidence of pelvic
inflammatory disease(PID) which leads to scarring that
blocks the fallopian tubes. The increased use of
intrauterine devices(IUD) contributes to the rise in PID
because 40% of infections associated with IUD use are
asymptomatic and remain untreated.
• Ovarian problems include anovulation, oligo-ovulation
and polycystic ovary syndrome. Secretory malfunctions
also contribute: for example, inadequate progesterone
secretion or an inadequate luteal phase will interfere
with the ability of a fertilized ovum to be maintained
Factors contributing to male infertility:
• Congenital factors include maternal history of DES
ingestion during pregnancy and absence of the vas
deferens or the testes.
• Ejaculation abnormalities include retrograde
ejaculation associated with diabetes, nerve damage,
medications or surgical trauma.
• Sperm abnormalities includes inadequate sperm
production or maturation, inadequate motility, blockage
of sperm along the male reproductive tract and an
inability to deposit sperm in the vagina.
• Testicular abnormalities include those due to illness for
example, orchitis associated with mumps after puberty,
cryptorchidism, trauma or irradiation
• Coital difficulties may occur owing to obesity or spinal
nerve damage.
• Drugs such as methotrexate, amebicides, sex hormones
and nitrofurantoin may interfere with spermatogenesis.
• Other factors that interfere with sperm or semen
production include infections such as sexually
transmitted diseases, stress, inadequate nutrition,
excessive alcohol intake and nicotine.
• Interactive problems (unexplained subfertility), resulting from causes
specific to each couple, include:
a) Insufficient frequency of sexual intercourse
b) Poor timing of intercourse
c) Development of antibodies against a partner’s sperm
d) Use of potentially spermicidal lubricants, such as petroleum jelly and
some water-based lubricants
e) Inability of the sperm to penetrate the egg
Diagnostic evaluation
1. Semen analysis

a) The test is performed after 48 to 72 hours of

abstinence from orgasm to avoid false low readings.
b) Repeated serial analysis is done 74 days apart.
c) Sperm count, volume of ejaculate, infection, seminal
viscosity and presence or absence of agglutination of
sperm are considered
2. Cervical mucus assessment
a) At the height of estrogen stimulation, just before ovulation, cervical
mucus is thin, has a low viscosity and cellularity, and appears in a large
amount. It forms a fernlike pattern when allowed to dry on a glass slide.
This pattern is observable under a microscope. At this point during the
cycle, the cervical mucus also can be stretched into long strands.
b) When progesterone levels rise, just after ovulation during the luteal
phase, a fern pattern is no longer present.
c) Fern test
d) Spinnbarkeit test
3. Postcoital test
a) The couple is instructed to have sexual intercourse at
the presumed time of ovulation after a 48-hour period
of abstinence.
b) Immediately after intercourse, a sample of cervical
mucus is examined microscopically to detect
characteristics that enhance sperm survival and to
assess adequacy of estrogen production.
4. Basal temperature recordings
a) For several cycles, the woman takes and records oral
temperatures daily when awakening.
b) A biphasic pattern with persistent temperature
elevation for 12- 14 days before menstruation indicates
that ovulation has occurred.
5. Hormonal assessment of ovulatory function
a) Gonadotropin levels-FSH and LH provide valuable information
concerning ovulatory function.
b) Progesterone assays furnish the best evidence of ovulation and
corpus luteum function.
c) Elevated levels of prolactin are a frequent cause of ovulatory
dysfunction, which may include anovulation or amenorrhea
d) Thyroid-stimulating hormone -hypothyroidism may have a profound
effect on ovulatory function, causing menstrual irregularities and
bleeding problems.
e) Excessive androgen levels usually result in such clinical symptoms as
ovulatory dysfunction, which may include anovulation and
amenorrhea.
6. Endometrial biopsy
a.) Endometrial biopsy provides direct histologic
information about the endometrial tissue.
b.) If adequate secretory tissue is identified, secretion of
progesterone and luteinizing hormone Is normal,
indicating ovulation has occurred.
7. Hysterosalpingography
a) A radiopaque dye is injected through the cervix into the uterus.
Fluoroscopy shows whether the fallopian tubes fill with dye.
b) A radiograph is taken 24 hours later to determine if the dye has
dispersed in the pelvic cavity, an indication of fallopian tube
patency.
c) The study must be done after menstruation has ceased to
prevent the possibility of old menstrual blood being pushed
into the tubes and causing infection.
d) The study also must be done before ovulation to prevent
pushing a fertilized ovum out through the fimbrial end of the
tubes.
8. Transvaginal ultrasound imaging
a) Ultrasound waves can be used to determine the patency of the fallopian
tubes and the depth and consistency of the lining of the uterus.
b) Sonohysterography is a non-invasive ultrasound technique that can be
carried out at any time during the menstrual cycle.
c) Transvaginal ultrasound is the method of choice for monitoring women
undergoing ovulation induction cycles, timing ovulation for insemination
and intercourse, retrieving oocytes for in vitro fertilization and
monitoring early pregnancy.
9. Hysteroscopy

a) Is a visual inspection of the uterus through a

hysteroscope.
b) A thin hollow tube is inserted through the cervix.
c) It is helpful in detecting uterine adhesions or other
abnormalities
10. Other tests

a) Immunoassays of semen and male or female serum

are done to determine if antibody formation against
the partner’s sperm is a factor in infertility.
b) Sperm penetration assay is an in vitro test to
determine the ability of the sperm to penetrate the
zona pellucida of the ova.
Medical management
 A. Management of an Underlying Problem

1. General suggestions
a) alter acidic cervical mucus by having the woman douche with an alkaline
solution 30 minutes before the intercourse.
b) Remove environmental hazards associated with oligospermia for
example, tight underclothes, hot tubs or saunas, and certain drugs,
chemicals and toxins.
2. Surgery
a) Correct anatomic defects and remove obstructions in the female
reproductive tract
Remove uterine fibroid tumors
Cerclage an incompetent cervix
Perform microsurgery to open blocked fallopian tubes
a) Ligate varicocele in the man.
3. Medications

The following medications may be used to treat infertility:

a) Antibiotic therapy to treat infections
b) Testosterone to treat oligospermia
c) Estrogen therapy to increase the abundance of cervical mucus and
enhance ferning and spinnbarkeit.
d) Ovulation-induction medications to treat anovulation.
 Medications
Hormone classification Uses
used for infertility
Gonadotropins(Menotropins,
Pergonal, Humegon)
Androgenic anabolic
hormone(Testosterone, Andro,
Histerone, Testamone, Testoject)
Estrogen(Estrogen, Depogen,
Premarin CES)
Estrogen agonist(Clomid)
Selected interventions
Management of infertility; production
of ovarian follicular development and
growth; followed by administration of
human chorionic gonadotropin to
produce ovulation
Possible increase of sperm count and
motility
Restoration of hormone balance and
maintenance of ovarian function
Stimulation of the ovary.
Observe for the following because
treatment may need to be
discontinued: ovarian enlargement,
febrile reaction, multiple pregnancies,
ovarian hyperstimulation
syndrome(abdominal and GI
symptom and peripheral edema)
Monitor for side effects: rash,
dizziness, fatigue hirsutism, increased
blood pressure, weight gain,
increased blood glucose
Monitor for side effects; headache,
dizziness, nausea, breast tenderness,
thromboembolism, breakthrough
bleeding, leg cramps.
Monitor for: abdominal distention,
nausea, vomiting, breast tenderness,
ovarian enlargement, multiple births
may occur
Hormone classification
Semisynthetic ergot
derivative(Bromocripitine,
Parlodel)
Synthetic androgenic
hormone(Danazol, Danocrine)
Uses
High levels of prolactin may impair
production of FSH and LH or block
their action on the ovaries
Treating infertility caused by
endometriosis by suppressing
ovulation and menstruation;
temporary suppression has been
shown to result in healing of the
endometriosis
Selected interventions
Take drug with food, take 1st dose
when lying down at bedtime,
begin therapy during menses.
Has teratogenic effect on fetal
development if pregnancy occurs
during therapy.
Discontinue at a time of
anticipated ovulation once normal
ovulatory cycle is established.
Ensure client is not pregnant
beginning therapy.
Alert the client for weight gain,
changes in hair distribution and
other androgenic effects, bruising,
bleeding, chills, fever, sore throat,
vaginal itching.
 B. Assisted reproductive techniques

1. Artificial Insemination
2. In vitro fertilization (IVF)
3. Gamete intrafallopian transfer
4. Zygote embryo transfer
5. Surrogate embryo transfer (SET)
6. Intracytoplasmic sperm injection (ICSI)
7. Surrogate mothering
8. Complementary and alternative therapy
 C. Activities to aid conception
1. Determine the time of ovulation by using basal body temperature, analysis of cervical
mucus, or a commercial kit to determine ovulation.
2. Plan sexual relations for every other day at the time of ovulation. More frequent coitus
may lower sperm count.
3. The male superior position is the ideal position because it places the sperm closest to the
opening of the cervix.
4. Elevating the woman’s hips on a small pillow during coitus will help to collect sperm
nearest to the cervical opening.
5. The woman should stay on her back with her knees drawn up for at least 20 minutes after
ejaculation to keep sperm near the cervical opening.
6. Do not use douches or artificial lubricants before or after intercourse because they may
interrupt sperm motility.
Care of the Infertile Couple
 1. Assessment
a) Evaluate the couple’s sexual history and reproductive history to rule out sexual dysfunction as a
cause of fertility.
b) Assess the couple’s knowledge of sexuality, sexual techniques and infertility.
c) Assess the couple’s lifestyle, including use of medicines, drugs and other substances; nutrition;
exercise; rest patterns; occupation.
d) Evaluate the couple’s psychosocial responses associated with infertility stage of emotional
healing, cultural influences, belief systems and effect on self-image.
e) Assess the general health, including illnesses, injuries, surgeries, and the woman’s menstrual
hx.
f) Determine lifestyle choices, including use of alcohol and drugs, hx of STD’s and number of sex
partners.
 2. Physical Examination

a) Complete a general physical exam.

b) Note distribution and condition of hair and fat.
c) Perform a careful examination of the genital tract for presence of infection,
condition of the cervix, size and position and mobility of the uterus.
 3. Laboratory and diagnostic studies

a) CBC
b) Triiodothyronine(T3),thyroxine(T4) and thyroid-stimulating hormone(TSH)
(thyroid function studies)
c) Urinalysis and culture represent normal kidney function and rule out infection
d) Serologic tests for syphilis
e) Rh factor and antibody titer
f) Sperm antibody tests and semen analysis
 B. Nursing Diagnosis

1) Anxiety
2) Ineffective family and individual coping
3) Decreased self-esteem
4) Knowledge deficit
5) Spiritual distress
6) Fear
7) Grief
8) Health-seeking behavior
 C. Nursing Role

1. Assist the couple in regaining sense of control.

2. Provide advocacy and support for decision making.
3. Provide anticipatory guidance.
4. Provide accurate information and dispel myths associated with infertility
that foster guilt, self-doubt and feelings of inadequacy.
5. Help the couple resolve their feelings about infertility.
That in all things God maybe glorified.