Jeannie Harper, PhD, RN Southeastern Louisiana University

OBJECTIVES Review the basics of conception Discuss the common causes of infertility Examine psychological impact of infertility in our society Describe common diagnoses and treatment of infertility. Discuss alternative reproductive therapies available to infertile couples.

Definition of Infertility Inability to conceive despite a year of well timed and unprotected intercourse

Infertility vs. Sterility Infertility implies subfertility or a prolonged time to conceive Sterility means inability to conceive Infertility may be: Primary Secondary

Incidence Of Infertility Affects 10% - 15% of all couples of reproductive age Prevalence increases with age – greater in women over 40 Controversial whether higher numbers in males due to increased incidence or improvements in diagnosis.

Causes of Infertility by Couple

FACTORS AFFECTING FEMALE INFERTILITY CONGENITAL OR DEVELOPMENTAL FACTORS HORMONAL FACTORS TUBAL (PERITONEAL) FACTORS UTERINE FACTORS VAGINAL-CERVICAL

FACTORS AFFECTING MALE INFERTILITY STRUCTURAL & HORMONAL FACTORS EXPOSURE TO ENVIRONMNETAL HAZARDS SUBSTANCE ABUSE

Couple’s Reaction to Infertility Female Reaction Loss of femininity and attractiveness Blame and Guilt Anxiety and Depression Male Reaction Mental anguish Inadequacy Loss of masculinity

CULTURAL FACTORS AFFECTING FERTILITY Religious Beliefs Conception as Beginning of Life Jewish Practices: Prohibitions regarding Intercourse Other Ethical Concerns

ASSESSMENT OF FEMALE INFERITILITY Complete H&P Detection of Ovulation Hormone Analysis Ultrasonography

ASSESSMENT OF FEMALE INFERTILITY Timed Endometrial Biopsy Laparoscopy Hysterosalpingography

ASSESSMENT OF MALE INFERTILITY Semen Analysis Ultrasonography

ASSESSMENT OF MALE & FEMALE INFERTILITY Postcoital Test Assess quality of cervical mucus and quality of sperm- cervical mucus interaction.

PLAN OF CARE Non Medical Education re menstrual cycle Appropriate timing of intercourse Avoidance of spermicides & high scrotal temperatures Herbal Alternative Measures (not proven clinically) E.g., nettle leaves, dong quai, St. Johns wart

PLAN OF CARE Medical Treatment of infections Treatment of endometriosis Ovulation inducing medications (e.g., Clomid) Stimulation of endometrial development (progesterone) Treatment of anti-sperm antibodies See table 10-3

PLAN OF CARE Assistive Reproductive Therapies (ART) These account for less that 1% of all US births. And less that 3% of infertility treatment. Associated with many ethical and legal issues.

Assistive Reproductive Therapies (ART) In Vitro Fertilization Steps in the Process Ovarian Stimulation Egg Retrieval Insemination Fertilization and Embryo Culture Embryo Transfer

Assistive Reproductive Therapies (ART) Gamete Intrafallopian Transfer (GIFT) Zygote Intrafallopian Transfer (ZIFT) Intrauterine Insemination (IUI) Intracytoplasmic Sperm Injection (ICSI)

Assistive Reproductive Therapies (ART) Oocyte Donation Therapeutic Donor Insemination (TDI) Surrogate Motherhood

PLAN OF CARE Psychological Debunk common myths Provide emotional support Refer for more information and support (e.g., RESOLVE, American Society for Reproductive Medicine, International Council on Infertility Information Dissemination)

FINANCING INFERTILITY TREATMENT Laparoscopy $2,850 - $8,100 Semen Analysis $50 - $120 Clomid (per cycle) $150 - $350 Intrauterine Insemination $250 - $700 ICSI $1200 IVF $8,000 - $12,000 GIFT $8,000 - $15,000 ZIFT $10,000-$15,000

Examples of Fertility Treatment Costs Timed IUI - $900 Clomid IUI - $950 FSH Intrauterine Insemination 1 cycle - $1,815 In Vitro Fertilization 1 cycle - $6,190 ICSI (May be needed for severe male factor infertility) - $1,500 Embryo cryopreservation (1 year of storage - $750) Frozen Embryo Transfer - $2,545 Center for Assisted Reproduction Embryo - Texas

STATES WITH MANDATED INSURANCE COVERAGE FOR INFERTILITY (9/2008) Arkansas California Connecticut Hawaii Illinois Louisiana Maryland Massachusetts Montana New Jersey New York Ohio Rhode Island Texas West Virginia

State Mandated Insurance Coverage for Infertility Treatment state-mandatedinsurancelist.jsp#Texas state-mandatedinsurancelist.jsp#Texas