NU 330 - Exam 1 - PP3 (fertility and Family Planning)

The Female Reproductive Cycle *may want to look at graphs

• The Ovarian Cycle

• Follicular phase (days 1–14)

• Immature follicle grows due to FSH

• Near end of phase the ovum is developed and mature

• Luteal phase (days 15–28)

▪ Begins when ovum leaves follicle

▪ If ovum is fertilized and implants (in the endometrium), it begins to secrete human chorionic gonadotropin (hCG)

• The Uterine Cycle

• Proliferative Phase

• Uterine lining starts to regrow (days 5- 7)

• Secretory phase

• Follows ovulation

• Increased vascularity of uterus in preparation for fertilized ovum

• Ischemic phase (if no fertilization occurred)

• Estrogen levels decrease

• Corpus luteum begins to degenerate

• Menstrual flow begins (back to phase one)

Neurohormonal Basis of the Women’s Reproductive Cycle

• Hypothalamus secretes gonadotropin- releasing hormone (GnRH)

• Causes anterior pituitary to release FSH and LH

• Follicle-stimulating hormone (FSH)

• Causes maturation of ovarian follicle

• As it matures it secretes increasing amounts of estrogen which in turn enhances the development of the follicle

• Luteinizing hormone (LH)

• Increases production of progesterone

• Causes release of mature follicle from ovary

*Neurohormonal: Hormones produced in the brain (hypothalamus and anterior pituitary

Effects of Women’s Hormones

• Estrogens

• Secreted by ovaries during childbearing years

• Control development of women’s secondary sex characteristics (breast development, menstrual cycle, widening of the hips, adipose tissue deposits)

• Promotes maturation of ovarian follicles

• Contributes to an increase in sexual drive

• Testosterone

• Secreted by the ovaries

• Works with estrogen to maintain and repair reproductive tissues and bone mass

• Progesterone

• Secreted by corpus luteum (on the ovary)

• Responsible for the temperature rise that occurs with ovulation and

maintaining the temp above the baseline after ovulation

• “Hormone of pregnancy”

▪ Has an effect on the uterus to allow pregnancy to be maintained

• Prostaglandins (PGs)

• Oxygenated fatty acids produced by cells of endometrium

Ovulation and Fertilization

*Occurs following the rapid growth of the follicle as the estrogen diminishes and the progesterone secretion begins (from the corpus luteum)

-At fertilization, the ovum and sperm unite as each of their chromosomal

material make up the DNA of the cells

-7-10 days after fertilization, implantation, or nidation, occurs. The zygote burrows into the endometrium, or decidua.

-Note where fertilization of the ovum occurs-- in the ampulla of the fallopian tube

-Ova are viable for 12-24 hours and sperm can be viable for up

o 48-72 hours

Male Reproduction

Seminal fluid (semen) and sperm:

 The anterior pituitary produces gonadotropins which promote the testes to produce testosterone and maintain spermatogenesis

 Seminal fluid provides nutrients to encourage sperm motility and viability. Sperm need an environment pH near 7.5 to survive

 The average volume for an ejaculation contains 200-500 million spermatozoa (only a hundred or so ever actually make it to the ovum).

 Once inside the female reproductive system, sperm can be viable up to 72 hours (some texts state that the sperm only live 24-48 hours) Testosterone: (not cyclic like a woman’s cycle)

 Responsible for the development of secondary sex characteristics (distribution of body hair, ejaculation of seminal fluid, development of male genital tract, certain behavioral patterns (aggressiveness) and sexual drive

Family Planning and Contraception

• Patient Education

• Choosing a contraceptive

• Advantages and disadvantages

• Patient’s age, childbearing plans

• Side effects, safety, contraindications

• Health considerations

• Failure rate, compliance, ease of use

• Partner’s support

• Cost burden

Natural Family Planning (NFP) and Calendar Rhythm Method

• Abstinence during fertile days

• Based upon the premise that ovum are viable for 12-24 hours, that sperm can fertilize an ovum up to 48 to 72 hours and that ovulation occurs on days 12-16 of a woman’s cycle

-Not ideal for:

• Women with irregular menstrual cycles

• Women who are breastfeeding

• Women in perimenopaus

Basal body temperature

• Great choice for those trying to conceive but also can be used as birth control

• Take temperature every day at the same time (usually first thing in the am before arising)

• A drop in temperature signals ovulation is occurring (estrogen has decreased). The next 3 days will see the temperature rise by 0.5 to 1.0ºF

• The most fertile time is when the temperature drops and then 24 hours after the temp rises; or abstain 3 days post-temperature change if avoiding pregnancy

• Effectiveness influenced by:

• Illness

• Emotional distress

• Interrupted sleep cycles

• Smoking and alcohol use

• Use of an electric blanket

Billings Cervical Mucous Ovulation metho

• Assessment of cervical mucous (hostile vs fertile)

• Following ovulation, cervical mucous is thin and watery to promote sperm motility and viability

Symptothermal method

Signs of increased libido, abdominal bloating, mittelschmerz; one-sided, lower abdominal pain associated with ovulation (German for "middle pain”, occurs midway through a menstrual cycle)

Lactational amenorrhea

• Exclusive breastfeeding for the first 3 months post delivery to establish and continue:

o At least 8-12 feedings/day (every 3-4 hours)

o At least one feeding at night

o Effective for at least 6 months

o Note: ovulation usually returns before menstruation

Fertility Awareness-Based Methods

Advantages:

• Generally acceptable to all religious groups

• No side effects & reversible

• May be used to either achieve a pregnancy or to avoid a pregnancy

• Low or minimal cost

Disadvantages:

• Requires daily observation

• Most effective for regular cycles

• May have to avoid intercourse for up to 2+ weeks/month

• Restrictive of sexual spontaneity

• Does NOT protect against STIs

Education:

• Takes 3-6 cycles to determine a baseline

Spermicide

• Nonoxynl-9 (N-9) approved for U.S. use

• Available as: Jelly, foam, vaginal film, suppository

• Minimally effective alone, use with barrier method increases effectiveness

• Not effective against sexually transmitted infections (STIs)

• Action: Provides physical and chemical action which inactivates the sperm before they reach and enter the cervical os

• Advantages: ease of application, good back-up system, relatively inexpensive, non-prescription, kills many pathogens

• Disadvantages: must be placed deep in vagina, possible teratogenic effects to sperm; maximum effect is one hour (may need to reapply), decreased tactile stimulation, possible vaginal irritation, increased incidence of UT

Barrier Methods of Contraception

• Requires use and placement prior to every act

• Few side effects, safe (except if latex allergy)

• Silicone, polyurethane, lambskin also available

Male condom:

• Advantages: decreased risk of many STIs, non-prescription, relatively inexpensive, few side effects (possible local irritation to latex or spermicide); good choice for the early Postpartum period

• Disadvantages: potential allergy to latex, polyurethane condoms less effective at preventing the spread of STIs; some blunting of sensations, skin irritation can result from spermicides; takes motivation to use each time

Female condom:

• Advantages: Protects better against STIs than the male condom; heightened sensation

for men over the male condom; may be placed prior to intercourse

• Disadvantages: More expensive, more limited access to purchase; difficult to use and uncomfortable; may be accidentally pulled out of the vagina during intercourse

Barrier Methods of Contraception

Diaphragm

• Initially fitted by healthcare provider

• Not recommended for women with history of UTI

• Must be inserted before intercourse in combination with spermicidal gel

• Decreases risk for HPV as it protects and covers the cervix

• Relatively inexpensive

Cervical cap or sponge

• Similar to diaphragm but smaller

• Strap over dome for easier removal

• May insert up to 6 hours prior to intercourse

• Increased risk for toxic shock syndrome and UTIs

▪ 3 sizes

▪ Available by prescription

Intrauterine Contraception

Action:

• T-shaped intra-uterine device (IUD) with attached string inserted in the uterus by a provider

• Causes a foreign body inflammatory response which inhibits endometrium development and thickens cervical mucous

Copper IUD (ParaGard T 380A)

• Provides protection for 10 years

Hormonal IUD (Mirena, Skyla)

• Provides protection for 3-5 years or longer

• 20mcg of progesterone released daily which suppresses ovulation and endometrium development

Advantages

• High rate of effectiveness

• Continuous contraceptive

• Improves spontaneity

• Reversible after removal (ParaGard 1-2 months, hormonal can be a few months)

• Breastfeeding mothers can safely use

Possible disadvantages

• Increased bleeding

• Increased risk of pelvic infection

• Risk for perforation of the uterus during insertion

• Dysmenorrhea

• Expulsion of the device (self-check strings monthly)

Hormonal Contraception

• Forms such as pill, injectable, implant, vaginal ring, or skin patch

• Combination of estrogen and progestin or progestin-only (mini-pill or

injection) hormones

• Progestin-only is a safe choice for breastfeeding mothers (estrogen can

decrease or inhibit breastmilk production)

• Action: Hormonal regulatory method to suppress secretion of FSH and

LH; thus follicles don’t mature and ovulation is inhibited; also affects

tubal motility, cervical mucous and endometrial development

*The lower the dose of estrogen, the fewer side of effects

Combined Oral Contraceptive (COC)

Contraindications

• Pregnancy

• Previous history of thromboembolic disease

• Acute or chronic liver disease

• Presence of estrogen-dependent carcinomas

• Undiagnosed uterine bleeding

• Heavy smoking

• History of cardiovascular disease

• Gallbladder disease

• Hypertension

• Diabetes

• Hyperlipidemia

• Hypercoagulable disorders

• Migraine with visual disturbance

Non-contraceptive benefits

• Relieve menstrual symptoms, premenstrual syndrome

• Treat endometriosis, irregular cycles

• Decrease cramps and flow

• Reduce incidence of:

• Ectopic pregnancy

• Pelvic inflammatory disease (PID)

• Endometrial, ovarian, and colorectal cancer

• Postmenopausal osteoporosis

• Iron deficiency anemia

• Benign breast disease

Combination Oral Contraceptive Patient Education

• No smoking due to the increased risk of PE, DVT, hypertension

• Other medications may make OCP less effective (antibiotics, antacids, vitamin C)

• Possible side effects; headache, breast tenderness, nausea, bloating,

decreased libido, depression, weight gain, and more (see DLL textbook

table 4-2 on p. 64)

emergency contraception

• May cause nausea and vomiting (higher dosage than daily COCs)

• Should not be confused with medical abortion

• Initiate within 72 hours or up to 5 days after unprotected intercourse, sexual assault, or failed contraception

• Action: Inhibits ovulation, increases hostility of endometrium to sperm/chemical and pH changes

• Commonly known by the brand name “Plan B”

Transdermal Hormonal Contraception

• Applied for 3 weeks, then reapply after one week off (period week)

• Slowly releases estrogen and progestin through the skin

• Apply to the buttocks, upper body (not the breasts) abdomen below the waist, or upper outer arm

• Replace patch if becomes loose; may still swim/tub bathe

• Candidates should weigh less than 198 pounds and do not have contraindicating skin disorders or risk for VTE

Nexplanon

• Radiopaque, single-capsule implant inserted subdermally

• Prevents ovulation, stays for 3 years

• Possible side effects of spotting, irregular bleeding, headaches, weight gain, fluid retention, depression

• Minor surgical procedure required to insert and remove the implant

Vaginal Ring

• Commonly known by the brand name "NuvaRing”

• Place in upper vagina where it remains for 3 weeks, then reapply after one week off (period week)

• Slowly releases estrogen and progestin

• If NuvaRring falls out, needs to be replaced within 3 hours after rinsing with warm water

Progestin-Only Pill or Injection

Minipill

▪ Used primarily by nursing women and those with high risks/cardiovascular disease

Long-acting progestin injections

▪ Depo-Provera

▪ Subcutaneous shot every 10–13 weeks

▪ Return of fertility may take weeks or months

▪ Prolonged use (2+ years) increases the risk of bone loss and the risk of osteoporosis

Operative Sterilization

Vasectomy

• Bilateral ligation of vas deferens

• Educate to use back-up method until approximately 20 ejaculations occur to clear vas deferens of remaining sperm

• Possible side effects: similar to any surgical procedure, and including spontaneous re- anastomosis (very rare)

• Reversal is possible but not always results in pregnancy

Tubal ligation

• Cut and removal of part of each fallopian tube

• Laparotomy following cesarean birth or abdominal surgery

• Mini-laparotomy soon after vaginal birth

• Laparoscopy when woman is not pregnant

• Possible side effects: similar to any abdominal surgical procedure

• Reversal depends on type of procedure

Clinical Interruption of Pregnancy

• Indications may include disease or health state that jeopardizes the mother’s or fetus’s life, failure of contraceptive method, or sexual assault

• Based on weeks of gestation and state law

Medical Interruption:

• Mifepristone and/or misoprostol

• Used within first 10 weeks since last menstrual period

• Mifepristone (anti-progesterone) stops the pregnancy

• Misoprostol “Cytotec” (prostaglandin) causes smooth muscle (uterine) contractions to expel the products of conception

Surgical Interruption:

• Manual dilation and vacuum curettage (D & C)

*isoprostol is also used to help expel tissue from the uterus In pregnancies that are no longer viable (no heartbeat, no growth)– called a miscarriage or missed abortion prior to 20 weeks

Preconception Health Measures for Patient Education

Modifiable risk factors

• Smoking

• Alcohol

• Social or street drugs

• Caffeine

• Medications

• Environmental hazards

Nutrition

• Average weight for body build and height

• Folic acid supplementation (Prenatal Vitamin)

• Balanced diet

Exercise

• Establish regular plan at least 3 months before planning to become pregnant

Physical examination

• Both partners

▪ Medical conditions, STIs, anemia, familial genetic disorders

Woman

▪ Urinalysis, CBC, blood type and Rh factor, Pap smear

Infertility

Infertility considered as;

• Failure to achieve a successful pregnancy after 12 months or more of regular unprotected intercourse

• OR 6 months for those with risk factors or over age 35

Primary infertility

• Woman with no prior pregnancies

Secondary infertility

• Couples who have been able to conceive previously

Factors

• Environmental exposures

• Weight, nutritional status

• Endocrine disorders

• Medications, smoking, drug use

• Unexplained or both partners represent 10% of infertility cases

• Men’s factors represent 30%

• Women’s factors represent 60%

Common Pharmacologic Methods for Managing Infertility

Oral medication: Clomiphene citrate (Clomid, Serophene)

-Action: Induces ovulation by increasing the secretion of GnRH (hypothalamus), LH, and FSH (anterior pituitary) which stimulate follicle growth within the ovaries

Injectable medication: Gonadotropins; Human menopausal gonadotropin (hMG) (Repronex, Menopur)

-Action: Stimulates the follicle to mature and release egg. Used if Clomiphene unsuccessful or to prepare for egg retrieval (assisted reproduction)

-Multiple pregnancy risk is higher; close monitoring by ultrasound and serum estradiol levels to minimize the risk of ovarian hyperstimulation syndrome (producing too many ovarian follicles = possibility of multiple ovum waiting to be fertilized

*Metformin (oral hypoglycemic)

• Polycystic ovarian syndrome (PCOS) = insulin resistance = decreased fertility

• Insulin-Sensitizing Agents can help induce ovulation in women with PCOS

Methods of Managing Infertility

In vitro fertilization (IVF)

• Cases in which infertility has resulted from tubal factors/mucus abnormalities/cervical and other factors

• Ovum mixed with sperm in a culture medium with fertilization confirmed about 17 hours later

Therapeutic insemination (Intrauterine Insemination, IUI)

• Husband or Donor sperm

• Used if low sperm count, decreased motility or anatomic defects prevent the sperm from getting to the cervix

Surrogacy

• Pregnancy achieved through IUI or in-vitro

• Could raise legal, ethical, or religious concerns

Adoption

• Closed or open, handled by attorney or agency

• Overseas adoptions

• Some involve waiting periods, setbacks, high cos

Nursing Care Management

• For the couple dealing with infertility

• Financial, physical, emotional resources

• Awareness of the couples’ emotional needs

• Consideration of other methods attempted but unsuccessful

• Nursing interventions

▪Recognize infertility’s affect on lives, future plans

▪Allow to grieve loss of potential offspring

▪Assesses and responds to emotional, educational needs

▪Consider referral to mental health professionals