KERALA UNIVERSITY OF HEALTH

SCIENCES THRISSUR

OBSTETRICS AND
GYAECOLOGICAL NURSING

INFERTILITY

PRESENTED BY:
SUBITHA BABU
JOSCO COLLEGE OF
NURSING EDAPPON
 OBJECTIVES:
General objectives:
At the end of the seminar student
will have in-depth knowledge
regarding infertility, its causes and
diagnostic evaluation and its
management.
Specific objectives:
At the end of the seminar student will able
to:
 Define infertility
 Explain the types of infertility
Factors required for fertility in male and
female
Explain the causes of male and female
infertility
 Identify diagnostic tests of infertility
Explain the management of male and
female infertility and also the management
of unexplained infertility
Discuss the role of nurse in management
of infertility
 INTRODUCTION

Infertility primarily refers to the

biological inability of a person to
contribute to conception. Infertility
is the failure of a couple to become
pregnant after one year of regular,
unprotected intercourse. In both men
and women the fertility process is
complex.
 INTRODUCTION

Infertility affects about 10% of all

couples. Infertility problems are due
to female as well as male infertility
or combine both. . Although testing
of infertility in women, it is equally
important for the male partner to be
tested at the same time.
 INCIDENCE

Generally, worldwide it is estimated

that one in eight couples have
problems conceiving. Nearly 80% of
couples achieve conception, if they
so desire within 1 year of having
regular intercourse with adequate
frequency (four to five times a
week). Another 10% remain infertile
by the end of 3rd year.
 INCIDENCE

According to the Indian Society of

Assisted Reproduction, infertility
currently affects about 10 to 14
percent of the Indian population,
with higher rates in urban areas
where one out of eight couples is
impacted.
Nearly 27.5 million couples
actively trying to conceive suffer
from infertility in India.
 DEFINITION

Infertility is defined as a failure to

conceive within one or more years
of regular unprotected intercourse.
Subfertility refers to a state in
which a couple has tried
unsuccessfully to have a child for
a year or more. The term
subfertile means less fertile than a
regular couple.
 TYPE OF INFERTILITY

Primary infertility denotes

couples who have never been able
to conceive.
 TYPE OF INFERTILITY
Secondary infertility indicates
difficulty conceiving after
already having conceived (either
carried pregnancy to term or had
a miscarriage).
 FACTORS REQUIRED FOR
FERTILITY (MALE AND
FEMALE)
Healthy spermatozoa should be
deposited high in the vagina at
or near the cervix.
Capacitation and acrosome
reaction; spermatozoa should
undergo changes and acquire
motility in cervical canal.
Motility: spermatozoa should
ascend through the cervix into
the uterine cavity and fallopian
tube.
 FACTORS REQUIRED FOR
FERTILITY (MALE AND
FEMALE
Ovulation: Ovum should reach the
fimbriated end of the tube.
Patent fallopian tube: Fertilization
should occur at the ampulla of the
tube.
Transportation of fertilized ovum to
uterine cavity in 3-4 days, the
fertilized ovum should reach the
uterine cavity for nidation.
 CAUSES OF INFERTILITY

15 %

40 %
MALE FACTORS THAT CAUSES
INFERTILITY

• Defective spermatogenesis
• Obstruction of the efferent ducts
• Failure to deposit sperm
• Errors in seminal fluid
 Defective spermatogenesis

A. Congenital: Undescended testes

are a congenital condition in which
Spermatogeneis is depressed. Vas
deferens is absent bilaterally in 1-
2% of such men.
 Defective spermatogenesis

B. Hypospadias causes failure

to deposit sperm high in the
vagina.
 Defective spermatogenesis
D. Infection: Mumps orchitis after
puberty may permanently damage
Spermatogeneis. In chronic systemic
illnesses like bronchiectasis, the
quality of sperm is adversely
affected. Infection of the seminal
vesicle or prostate depresses sperm
count.
 Defective spermatogenesis
C. Thermal factor: The scrotal
temperature has to 10F-20F less than
the body temperature. It is raised in
conditions such as varicocele, big
hydrocele. Other causes are using
tight undergarments or working in
hot atmosphere
 Defective spermatogenesis

E.Gonadotropin suppression: This

happens in chronic debilitating
diseases, malnutrition, heavy
smoking and with high alcoholic
consumption.
 Defective spermatogenesis

F. Endocrine factors: follicle-

stimulating hormone (FSH) level
is seen raised in idiopathic
testicular failure.
Hypoprolactinemia is associated
with impotence.
 Defective spermatogenesis

G. Loss of sperm motility

(asthenozoospermia and abnormal
sperm morphology are seen in
some males).

H. Genetic: Common
chromosomal abnormality in
azoospermic male is Klinefelter’s
syndrome (47, XXY).
 Defective spermatogenesis

I. Iatrogenic: Radiation, cytotoxic

drugs, beta (β)-blockers,
antihypertensive, anticonvulsants
and antidepressant drugs are likely
to hinder spermatogenesis.
 Defective spermatogenesis

J. Immunological factor:
Antibiotics against spermatozoa
surface antigens may cause
infertility. This causes clumping of
spermatozoa after ejaculation.
Obstruction of the efferent ducts:

The efferent ducts may be

obstructed by tubercular infections.
Surgical trauma during vasectomy
or herniorrhaphy may lead to
obstruction.
Failure to deposit sperm high in the
vagina (coital problems)
Erectile dysfunction
Ejaculatory defects such as
premature, retrograde or absence
of ejaculation
Hypospadias
 Errors in seminal fluid:

Unusually high or low volume of

ejaculate (normal volume is 2ml
or more).
Low-fructose content.
High-prostaglandin content.
 Normal semen values as
determined by World Health
Organization (WHO) are given in
Semen tablevalue
Reference
parameters
Volume 20ml or more

pH 7.2-7.8

Sperm 20 million per ml or more

concentration
Motility 50% or more with progressive forward
motility
Morphology 15% or more in normal form

Viability 75% or more living

Leukocytes Less than one million per ml

 CAUSES OF
FEMALE
INFERTILITY
 Ovarian factors
 Uterine factors
Cervical factors
Vaginal factors (implicated)
 Combined factors
Age of wife beyond 35 years and
advancing age in men
Infrequent intercourse (less than 4-5
per week) during fertile period
(around ovulation)
Apareunia (failure of emission of
semen/ejaculation) and
dyspareunia
 Combined factors
 Anxiety and apprehension
Use of lubricants during
intercourse, which may
be spermicidal
Immunological factors (antisperm
antibiotics)
INVESTIGATION OF FEMALE

HISTORY

EXAMINATION

DIAGNOSTIC EVALUATION
 HISTORY
TAKING
MARRAIGE

MEDICAL & SURGICAL

MENSTRUAL

PREVIOUS OBSTETRIC

CONTRACEPTIVE PRACTICE

SEXUAL PROBLEMS
 Examinations
General examination: Obesity,
abnormal distribution of hair and
underdevelopment of secondary
sex characteristics.
Systemic examination:
Hypertension, organic heart
disease, endocrinopathies.
 Examinations
Gynecologic examination: Evidence
of vaginal infection, undue
elongation of cervix, uterine size,
position, nodules in the pouch of
Douglass.
Speculum examination: For
presence of cervical discharge,
which if present needs to be tested
for infection.
 DIAGNOSTIC EVALUATION
Menstrual history: Look for
evidences of ovulation such
as:
Regular, normal menstrual loss
between the ages of 20 and 35.
Mid-menstrual bleeding (spotting)
or pain, or excessive vaginal
discharge suggestive of
mittelschmerz syndrome.
Features of primary dysmenorrheal
or premenstrual syndrome (PMS)
 Diagnostic evaluation
Cervical mucus study:
Disappearance of fern pattern of the
mucus beyond 22nd day of cycle,
progesterone causes dissolution of
sodium crystals. Following
ovulation, there is a loss of
stretchability or elasticity is an
evidence of ovulation. Fern test
during the cycle aids in determining
ovulation.
 Diagnostic evaluation
Endometrial biopsy
 Diagnostic evaluation

Sonography: Serial sonography

during midcycle can precisely
measure the Graafian follicle just
prior to ovulation (18-20mm):
The features of recent ovulation
are collapsed follicle and fluid in
the pouch of Douglas.
 Diagnostic evaluation

Laparoscopy: Laparoscopic
visualization of recent corpus luteum
or detection of the ovum from the
aspirated peritoneal fluid to the
pouch of Douglas is the direct
evidence to ovulation.
 Diagnostic evaluation
Insufflation test (Rubin’s test):
It is done to see the patency
of fallopian tubes. It is done by
pushing air or carbon dioxide
under-pressure through the cervical
canal. If the tubes are patent, air
reaches the peritoneal cavity. It is
done in the postmenstrual period at
least 2 days after stoppage of
menstrual bleeding.
 Diagnostic evaluation
Rubin’s test Positive
findings include:
Fall in the pressure when
raised beyond 120mm Hg.
Hissing sound heard on
auscultation on either iliac
fossa.
Shoulder pain experienced
by the patient due to irritation of
diaphragm by air.
 Diagnostic evaluation

Hysterosalpingography (HSG): In this

test, instead of air or carbon dioxide,
dye is introduced transcervically. The
test is done in the postmenstrual phase,
2 days after the stoppage of
menstruation. It is avoided if the women
as pelvic infection. It can precisely
detect the site of block in the tube. It can
reveal any abnormality in the uterus
such as fibroid or synechiae. A
disadvantage of HSG is radiation risk.
 Diagnostic evaluation
Hysterosalpingography (HSG)
 Diagnostic evaluation
Laparoscopic chromotubation
 Diagnostic evaluation
Sonosalpingography: This test
involves a slow injection of
physiological saline into the
uterine cavity using a pediatric
Foley’s catheter. The catheter
balloon is inflated at the level of
the cervix to prevent fluid leak.
Ultrasonography of the uterus and
fallopian is then
done. Ultrasound can follow the
fluid through the tube up to the
peritoneal cavity and in the pouch of
Douglas.
Diagnostic evaluation

Sonosalpingography
 MANAGEMENT OF
INFERTILITY

Management of infertility or
subfertility would depend upon the
causes identified, duration and age
of
the couple, especially the female.
 GENERAL
INSTRUCTIONS
Body weight: Overweight or
underweight of any partner should
be adequately dealt with to obtain
an optimal body weight.
Smoking and alcohol: Excess
smoking or alcohol consumption
to be avoided.
 GENERAL
INSTRUCTIONS
Ideal coital frequency: Intercourse
on multiple days during the fertile
window period, which includes the
five preceding and the day of
anticipated ovulation, should be
reviewed with the couple.
 GENERAL
INSTRUCTIONS
Use of at home ‘fertility monitor’
and checking of vaginal mucus
discharge to determine the optimal
timing of intercourse may be most
helpful.
 GENERAL INSTRUCTIONS
Use of LH surge kit: Use of the kit
can detect LH surge in urine by
getting a deep blue color of dipstick.
The test performed between 12th and
16th day of regular cycle and timed
intercourse over 24-36 hours after
the color change reasonably
succeeds to conception.
 GENERAL
INSTRUCTIONS
Avoidance of lubricants and
douches to be stressed.
The use of fertility impairing
medications should be avoided
by both partners if possible, e.g.
hormones.
 GENERAL
INSTRUCTIONS
Psychological support should be
offered as the couple may face
significant stress and sadness as
the investigations and
consultations progress.
 MANAGEMENT OF
MALE
1. GeneralINFERTILITY
care:
Improvement of general
health:
•Reduction of weight in obese
•Avoidance of alcohol and heavy
smoking
•Avoidance of tight and warm
undergarments
•Avoidance of occupation that may
elevate testicular temperature
1. General care:
 Avoiding medications that
interfere with
spermatogenesis such as:
• Cytotoxic drugs, anticonvulsants,
antidepressants and beta blockers.
2. Medications to treat specific
causes:
Human chorionic gonadotropin
(hCG)
Dopamine agonist (cabergoline) for
hyperprolactinemia and altered
testosterone level and to improve
libido, potency and fertility.
2. Medications to treat specific
causes:
The GnRH therapy for
hypogonadism.
Clomiphene citrate to increases
serum levels of FSH, LH and
testosterone.
Antibiotics for genital tract
infections.
3.Surgical treatment:

In men, whose testicular biopsy

shows normal spermatogenesis
and obstruction is suspected,
vasovasostomy may help.
Correction of hydrocele.
 MANAGEMENT OF
FEMALE INFERTILITY
1. For ovulatory dysfunction:
Induction of ovulation using drugs
such as FSH, hCG and GnRH.
Substitution therapy: Thyroxin for
hypothyroidism, antidiabetic drugs
for diabetes mellitus.
 MANAGEMENT OF
FEMALE
INFERTILITY
2. Surgery:
Laparoscopic ovarian drilling or
laser vaporization for polycystic
ovarian syndrome (PCOS).
 Surgical removal of adrenal
tumor.
Tubotubal anastomosis for adhesion
in tube.
MANAGEMENT OF
FEMALE INFERTILITY
2. Surgery:
Cannulation and balloon tuboplasty
for block in tube.
Fimbrioplasty for fimbrial
adhesions.
Adhesiolysis for separation or
division of adhesion.
Salpingostomy to create an opening
in tube in a complete occluded tube.
 MANAGEMENT OF
UNEXPALINED INFERTILITY
Unexplained or persistent infertility
refers to those couples who have
undergone complete basic infertility
workup and in whom no abnormality
has been detected and still remains
infertile. The reported evidence is
about 10-20%. About 60-80% of
those couple becomes pregnant
within 3 years without any
treatment.
ASSISTED REPRODUCTIVE
TECHNOLOGY
 DIFFERENT TECHNIQUES OF
ART
Intrauterine insemination
In vitro fertilization and embryo
transfer (NF-ET)
Gamete intrafallopian transfer
(GIFT)
Zygote intrafallopian
transfer(ZIFT)
Intracytoplasmic
sperm injection.
Intrauterine insemination
 In vitro fertilization and
embryo transfer (NF-ET)
Gamete intrafallopian transfer
(GIFT)
Zygote intrafallopian
transfer(ZIFT)
Intracytoplasmic sperm
injection
ROLE OF NURSE MIDWIFE
Nurses meet couple seeking help for
treatment of fertility in special centers
or clinics, where such services are
available. Those working in infertility
centers usually are the first contact
persons who coordinate various
activities for the couple’s treatment.
Their role with such couples includes
assessing, educating and counseling in
addition to therapeutic assistance as
they undergo tests and procedures.
 ROLE OF NURSE MIDWIFE
When a couple presents with
concerns about infertility, it is
important for the nurse to
understand that men and women are
very concerned and possibly
emotionally fragile.
 ROLE OF NURSE
MIDWIFE
Before or even beginning, the
medical aspect of care is important
to understand and assist the couple
to understand their motivation for
pregnancy and to offer support. The
couple should understand and accept
that the evaluation and treatment for
infertility will be stressful and
involves both partners throughout
the process. It is important to meet
the couple together.
 ROLE OF NURSE MIDWIFE

Nursing interventions include

assisting in reducing stress in the
relationship, encouraging
cooperation, protecting privacy
and fostering understanding.
During the period of therapy,
couples need to avoid smoking,
continue good diet, exercise,
maintain health and take folic acid
supplements, if prescribed.
 CONCLUSION:
In this seminar I conclude that
although infertility is common in both
men and women Infertility should be
evaluated after one year of
unprotected intercourse. History and
physical examination usually will
help to identify the etiology. If the
patients fail the initial therapies then
the proper referral should be made to
a reproductive specialist.
 SUMMARY:

Today we have about

discussed of infertility,
Definition
factors
contributing in fertility causes of
male , female infertility
management
and male and,
of
infertility female infertility
and unexplained
management and role of nurse in
management of infertility.
 BIBLIOGRAPHY
J.B.sharma Midwifery and
Gynaecological nursing .1st edition, A
vichalpublications; page no.390-400
AnnamaJacob. A comprehensive
Textbook of Midwifery&
gynaecological nursing, 4th
edition,jappee publication; page
no: 857-560
Hiralalkonar DC Dutta’s Textbook
of
Gynecology.7thedition,Jaypeepublica
t ion; page no.55-57
THANK
YOU