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Infertility and Contraception

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1 Infertility and Contraception

2 Primary infertility- no previous conceptions.
Infertility: inability to conceive > 1 year of regular sexual intercourse without contraception or inability to carry pregnancy to live birth. Incidence – 15% of couples of child-bearing age in U.S million American couples Primary infertility- no previous conceptions. Secondary infertility- previous birth but unable to conceive now. 2

3 Fertility Testing Procedures Semen analysis (inexpensive)
FSH, LH, estrogen, progesterone levels (blood test) Ovulation Determination by: Basal Body Temperature (temp slightly just before, then ~ 98.6 immediately > ovulation) ^ by ~ 1 degree (12-24 hours) 1st thing in morning before anything. Daily temps. plotted on graph for 3-4 mos. Urine Test Strip - LH upsurge < ovulation (ovulation predictor kits) Cervical Mucous Test home) “Spinnbarkeit “=stretching of cervical time of ovulation [d/t ^ estrogen] 3

4 How to Check for Ovulation…
Usually occurs on day 14 – 20 of menstrual cycle. Can be done with a regular cycle. *Count 14 days back from menses; accurate estimation of ovulation. Calendar Method: keep diary of ~ 6 months of menses. To help locate fertile days using calendar method, you would teach: Subtract 18 from shortest period and 11 from longest. (irregular cycle) Range of days - “possibly” fertile. 4

5 Fallopian Tube Obstructions
“Hysterosalpingography” - X-ray Imaging Radiologic exam of fallopian tubes using radiopaque dye. Catheter placed in cervix. Dye passes through filling uterus & fallopian tubes. Structures/adhesions in uterus/tubes & tube patency assessed Dye “blows out” tubes – clears obstruction; infertility resolved. 5

6 Hysteroscopy – visual inspection of uterus
hysteroscope: thin, hollow, lighted tube through cervix. Allows direct inspection of uterus. FU procedure to hysterosalpinography if abnormalities found. CO2/saline used. Diagnostic (local) or Operative (IV sedation) Surgical Evaluation: (general) Laparoscopy – insertion of thin, hollow, lighted tube thru incision made below umbilicus. CO2 gas inflates cavity. Examines fallopian tubes & ovaries; checks distance between ovaries & tubes; if distance too great, ovum can’t enter tube. Remove growths (fibroids, masses, polyps, scar tissue) TL, ectopic pregnancy, hysterectomy. Video camera used 6

7 Frequent Initial tests are: Semen Analysis
Basal Body Temp.[graph temp.] Sperm Penetration Assay [penetration ability] Post-coital Test Endometrial Bx. [assess level of estrogen & proges.] Other Fertility Procedures: Meds: Clomid, Serophene (^ ovulation) Increasing sperm count (abstinence 7-10 days) Myomectomy (fibroids) Tx vaginal infections (trichomoniasis, yeast, bacterial vaginosis) Artificial Insemination (insert sperm into uterus/cervix) In vitro fertilization (IVF): fertilize ovum w. sperm in lab & reinsert (~ 40 hrs). Removed by laparoscopy. 7

8 Alternatives to Childbirth:
Child-free living – allows for freedom, travel, careers, etc. Adoption – may take long time, costly Surrogate Motherhood – complicated legal & ethical issues may develop (woman may use own eggs or donated ova/sperm) 15% infertility cases in USA: Approx. 40% d/t male factors: 1/2 of these irreversibly infertile. Others treatable Approx. 60% d/t female factors: ~ 20% - 30% - ovulatory failure (hormonal) ~ 20% - 40% - tubal, uterine, vaginal problems (blocked tube, fibroids, endometriosis , PID, etc.) 8

9 normally hostile environment for sperm. Sperm live alkaline environ.
I. Female Factors Infections: Vaginitis & Cervicitis – makes environment hostile to sperm. [BV, yeast, trich, etc.] Bacterial vaginosis: ↑ growth of gardnerella; Vaginal environment becomes alkaline. Ph>5. TX infection. Cervical Problems – can affect survival/ mobility of sperm. Vagina [acidic] normally hostile environment for sperm. Sperm live alkaline environ. Cervical mucus alkalinic (basic) 2 days prior to ovulation d/t ^ estrogen. Sperm live for ~ 2 days. Low estrogen levels or cervicitis may slow or destroy sperm Estrogen for 6 mos. then try again. Endometriosis – endometrial tissue grows outside uterine cavity: ovaries & tubes - may impair ovarian function or block tubes ^ common in women with mother/sister affected. Can cause painful intercourse – dyspareunia. Slight risk of infertility. Retroversion- 25% - uterus tilts towards spine. 9

10 Hypo or hyperthyroidism also problem. Attempt to correct disorder
Endocrine Problems – Normal hormone activity needed for ovulation & development of healthy endometrium. Any dysfunction of pituitary, thyroid, adrenals, pancreas & ovaries can alter ovulation. Uncontrolled DM may lead to recurrent miscarriage. ex. PCOS Hypo or hyperthyroidism also problem. Attempt to correct disorder Structural Disorders Bicornate uterus; 2 horns. DES exposure. May need IVF. Uterine Fibroids - removed with myomectomy or May cause ↑ bleeding & prevent conception. May need hysterectomy 10

11 Primary Causes of Male Infertility: Impaired sperm
II. Male Factors Primary Causes of Male Infertility: Impaired sperm production/mobility/delivery; Testosterone deficiency (hypogonadism). Can be congenital or acquired. Problems in Sperm Production Average # deposited is 70 million/ml in 2-6 ml. Sperm count 20 million or less in 2-6 ml. suggests inadequate production. Causes: Infections - HPV, gonorrhea, chlamydia, epididymitis, testicular inflammation (orchitis) [mumps as adult] High fever from prolonged elevation of scrotal temperature; can cause irreversible infertility if before puberty Diseases (cystic fibrosis, sickle cell anemia); Testicular Cancer Testosterone deficiency - disorder in hypothalamic-pituitary-gonadal axis . Testosterone production ^ rapidly with puberty & decreases > age 50. Men with obesity, diabetes, HTN may be 2X as likely to have low testosterone levels. 11

12 Undescended Testicles (Cryptorchism) Correct with surgery.
Continued: Mechanical Factors: Variocele - varicose vein in spermatic cord. Blood does not cool - poor spermatogenesis. “Variocele Ligation” – improves sperm motility; not useful if sperm count < 10 mill/ml. Undescended Testicles (Cryptorchism) Correct with surgery. If testicles stay in abdominal cavity during puberty (irreversible) Absence of one/both testicles (anorchism) Injury/testicular trauma - trigger immune response (antibodies) impairs sperm: can’t swim thru cervical mucus or penetrate ovum. Environmental Influences: Exposure to radiation, chemicals, chemotherapy. Excessive smoking & ETOH, Drugs (anti- hypertensives & marijuana), DES exposure; Malnutrition, stress, hot tubs. 12

13 Problems with Sperm Mobility – Greater than 60% of sperm per
ejaculate should be motile for effective fertility. Factors that may affect mobility: Decreased Testosterone Infection (gonorrhea, chlamydia) Prostate Disease Problems with Sperm Transport: Obstruction d/t scar tissue; secondary to infections [gonorrhea], injury to Vas Deferens or Vasectomy. Retrograde ejaculation: Impaired muscles/nerves in bladder . Semen flows backward into bladder. > bladder surgery/congenital defect in urethra/bladder Rare; no orgasm. Retrieve semen in urine [voided or by catheterization]. Specimen buffered & sperm artificially inseminated. Hypospadias – congenital - sperm not high enough in vagina. Corrected after birth. 13

14 Sexual Technique/Timing - Provide counseling on:
III. Combined Problems [Male/Female] – Sexual technique, timing, immunologic responses. Sexual Technique/Timing - Provide counseling on: Position: Female on back with knees flexed for min. Fertility best if intercourse timed around ovulation. ~ 14 days < onset of next menses. Infrequent intercourse may lower sperm motility. Frequent : may lower # mature sperm. Immunologic Factors Women: antibodies against partner’s sperm (condoms for 6 mos) Men: autoimmune response to own sperm (steroids for sev. mos) 14

15 Support systems, occupational, educational, financial status.
H & P: Both partners Past/Present Health, Family, Social, Sexual, Reproductive, Risk factors, Illnesses, immunizations, allergies, hospitalizations, accidents, injuries, medications, habits. Support systems, occupational, educational, financial status. How long attempting pregnancy? Review of Systems (ROS): Both Partners Factors Significant for Both Partners: Exposure to radiation/toxic substances (lead); drugs, alcohol, marijuana, antihypertensives; STI’s; Maternal DES (diethylstilbestrol) exposure. PE of both partners 15

16 Management of Female Infertility
Infections: Terazol (yeast); Metronidazole (BV, trich) Endometriosis: Danazol (Danocrine) – suppresses ovulation, FSH/ LH, & menstruation. Stops endometrial tissue growth. Side effects: wt. gain, hot flashes After stopping med. menses resumes 1-6 wks. OR… Oral contraceptives continuously to suppress ovulation & tx endometriosis. Surgical removal – for moderate to severe disease [laparoscopy] Cervical Problems Estrogen Therapy – before ovulation for few months to enhance quality/quantity of cervical mucous. Cryosurgery – freeze surface of cervix; or recurrent cervicitis. Endocrine Problems – Ex: Hypothyroid – replacement therapy [Synthroid] Hyperthroid – surgery, radioiodine, meds. Fallopian Tube Problems - Infections, adhesions, endometriosis. Tx infections: Terazol, Metronidazole Hysterosalpingogram may unblock tubes (3%) with procedure. Lysis and excision of adhesions - with microsurgery. CO2 laser used for tubal occlusion. 16

17 Management of Male Infertility
Lifestyle Changes – Avoid heat sources, radiation/chemicals, ETOH/drugs, tobacco. Hormone Tx – Clomid or testosterone may ^ sperm count. Artificial Insemination: If above fails, artificial insemination with partner’s sperm. Also done when cervical environment hostile to sperm. Sperm are in highest concentration and most motile in 1st few drops of semen; ejaculate is split and 1st fraction saved. Multiple first fraction split ejaculates combined & inseminated. Impotency – failure to have erection. Can occur during infertility (need to perform). Supportive, non-judgmental atmosphere with reassurance - may be temporary. Counseling (high school years) - ^ drug/alcohol use occurs. 17

18 Newer Techniques in Managing Infertility In Vitro Fertilization (IVF)
Fertilization of mature ovum in lab & re-implantation of zygotes into uterus via laparoscopy. Fallopian tubes blocked in IVF candidates. Sperm sample must be normal. Costly. Success rate 20%. Not covered by insurance. Eggs can be frozen and fertilized later Gamete Intrafallopian Transfer (GIFT) Procedure Mature oocytes aspirated from female. Oocytes loaded into catheter with 100,000 washed sperm; contents placed in fimbrated end of fallopian tube via laparoscopy. More expensive [surgical] Dev. in Success rate 20-27%. Advantage over IVF: entire procedure performed during one laparoscopy & eliminates 2-day lab incubation period. Avoids potential damage to zygotes. 18

19 ZIFT: Zygote Intrafallopian Transfer
Fertilized zygote/embryo transferred into fallopian tube instead of uterus. Procedure also referred to as tubal embryo transfer must have healthy tubes for this to work. Options for Infertile Couple If treatments for infertility are unsuccessful, couple faced with several choices: Discontinue tx and remain childless OR….. Adoption – Couple needs to resolve loss of biologic parenting first so that adoptive parenting can be positive experience. Insemination with donor sperm. 19

20 Contraception Motives for use & choice of method unique to individuals. Range of alternatives discussed with clients so fully informed, satisfactory choice can be made. Nurse should encourage male’s participation in selection and counseling. If uncomfortable/ unqualified in giving contraceptive information, provide referral. Nurses who provide info. should be aware of all available methods; advantages/disadvantages. 20

21 Factors that Influence Contraceptive Choice
Individual’s stage in life cycle Personal values Religious, family, cultural background Expense Availability of bathroom facilities Frequency of intercourse Number of children desired Risk of pregnancy couple is willing to accept Presence of illness or physical problems Level of comfort with body and its functions 21

22 Risks: Nurse discusses:
Informed Consent Client is informed about method. Discuss methods, benefits, risks, effectiveness, contraindications. Risks: Nurse discusses: Side effects: weight gain, spotting, breast tenderness, nausea… Inconvenience; partner dissatisfaction; condoms, ring Benefits: Non-contraceptive & contraceptive benefits Therapeutic effects : reducing risk of PID; reduction in ovarian/uterine CA Important to prevent very high risk women. Effectiveness – client’s main concern Effectiveness Rate – in preventing pregnancy under ideal conditions True Effectiveness Rate – decreases because of human error. ** All methods have advantages and disadvantages 22

Methodology: Client measures & records BBT on her calendar until ovulation can be predicted. Action: Abstain from sex for several days before expected time of ovulation & for 3 days after ovulation. Rhythm Method (aka Calendar Method or Natural Family Planning Methodology: Client uses calendar to calculate fertile/infertile phases of menstrual cycle. Action: Abstain from sex during fertile period. Cervical Mucus Method (also called Ovulation Method or Billings Method) Methodology: Client assesses cervical mucus for changes in wetness, color, & clearness throughout menstrual cycle until ovulation can be predicted by cond.of mucus. Spinnbarkeit Action: Abstain from sex when mucus wet, clear, & stretchy. 23

24 Situational Contraceptives
Symptothermal Method Client assesses & records information about primary signs (Cycle days, cervical mucus changes) & secondary signs ( ↑ libido, abdominal bloating) until ovulation can be predicted. Abstain from sex for few days before expected ovulation & for 3 days after sex. Situational Contraceptives Coitus Interruptus (Withdrawal): Male withdraws from vagina & ejaculates away from woman’s external genitalia. One of least reliable methods . Mechanical Contraceptives Male Condom: Condom covers penis & prevents sperm from entering birth canal. Man applies condom to erect penis before vulva/vaginal contact. Most popular method of male contraception. Female Condom: fits over cervix & covers part of external genitalia & base of man’s penis; prevents sperm from entering birth canal. Woman inserts condom before sex. Not popular. 24

25 Diaphragm Cervical Cap
Methodology: Spermicide-filled diaphragm covers cervix preventing sperm from entering birth canal. Woman fills diaphragm with spermicidal cream & inserts it into vagina before sex. Must be left in place for 6 hours > sex; Re-fit with wt. gain or loss. Cervical Cap Method: Cup-shaped device filled with spermicidal cream fits snugly over cervix; held in place by suction. Prevents sperm from entering birth canal. Insert similar to diaphragm. May be left in place for up to 48 hours. least 20 minutes before inter. & leave in @ least 4 hrs. after sex 25

26 Sponge (back on market) Douching
Method: Client douches with saline solution directly > intercourse. * Ineffective: not recommended. May facilitate conception by pushing sperm farther up birth canal. Creams, Jellies, Foams, Vaginal Film, Suppositories Method: Substances destroy/immobilize sperm. Action: Client inserts into vagina before inter. NOTE: Spermicides minimally effective when used alone; effectiveness ↑ when used with diaphragm, cervical cap, or condom Leave in for 6 hours > sex. 26

27 Combination estrogen [20mcg - 35mcg] & progesterone.
Oral Contraceptives Combination estrogen [20mcg - 35mcg] & progesterone. [OC’s inhibit release of ovum & maintains cervical mucus that is hostile to sperm] * Take family/medical hx RISK: Thrombophlebitis. Contraindicated in women with HTN, over 35 & smoking, hx breast, ovarian, uterine CA. Take hormone pills for 21 days, takes placebo for 7 days, then restart next cycle of pills. To be effective - should be taken within 1 hour same time each day. Some antibiotics decrease OC effectiveness – use condoms. No protection against STD’s – TEACH: consistent condom use. Double up dose next day if pill is missed. 27

28 Combination hormones other than Oral… Vaginal Ring [once/month]
OC CONT. ^ risk of blood clots, esp. in smokers & women over 35 breakthrough bleeding Menstrual cycle & fertility return soon after stopping pill [99% of 187 women taking Lybrel for 1 year] within 90 days - recent study by Wyeth] Replacing Seasonal. (BTB 4x/year) Combination hormones other than Oral… Vaginal Ring [once/month] Ortho-Evra [patch] once/week 28

29 Long-Acting Progestin: Depo-Provera
Method: 150 mg. IM Injection - ceases ovulation & thickens cervical mucus to block sperm penetration. Effective for 3 months. 4x/yr. Return of fertility delayed for ~9 mos. Research shows: significant decrease in bone mass in all females especially teens. Counsel: Calcium in diet; Weight bearing exercises. Use limited to 2-3 years; recommend IUD in monogamous couples; Bone density scan for continued use > 2-3 yrs. Subdermal Implants (Norplant); no longer used in US; high rate of infection. Implanon - single rod available. Good for 3 years; uses progestin only. 29

30 Intrauterine Device (IUD)
Method: IUD immobilizes sperm & impedes their progress from cervix through uterus to fallopian tubes. Also causes inflammatory response of endometrium; spermicidal effect. IUD inserted by MD/NP into uterus, String visible at cervix. Check for string > each menses. Can perforate uterus “Mirena” has hormones; good for 5 yrs. “Copper T” [Paraguard] (10-12 years) Multiple cases of STI’s [gonorrhea, chlamydia] can cause PID; recommended for monogamous couples only. 30

31 Emergency Contraception: Plan B (OTC – 18 yrs or older)
Within 72 hours of unprotected sex. Does not cause abortion if implantation has occurred. Operative Sterilization Vasectomy Method: Vas deferens on both sides of scrotum surgically severed, interrupting flow of sperm from epididymis. Often can’t be reversed d/t scarring. Semen will not contain sperm. Tubal Ligation Method: Fallopian tubes are surgically severed preventing ovum & sperm from meeting. Can be reversed; costly. May not be covered by insurance. Reversal has ^ rate of ectopic preg. 31

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