Infertility Issues Lecture Notes

Infertility Issues

Overview of Infertility Issues

  • Essential components of fertility

  • Physical and psychosocial issues

  • Assessment of female and male fertility

  • Methods of managing infertility

  • Legal and Ethical Issues

  • Adoption

  • Nursing Care management

Definition of Infertility

  • Infertility is defined as the inability to conceive after twelve months of frequent, unprotected intercourse.

  • Prevalence: Affects approximately 10-15% of couples in the United States.

Causes of Infertility

  • Female factor: 40%

  • Male factor: 20%

  • Combination/Unexplained: 30-40%

  • Contributing factors include:
      - Delayed childbearing
      - Weight issues
      - Sexually Transmitted Infections (STIs)
      - Stress
      - Smoking

Initial Investigation

  • Comprehensive history taking for both female and male partners:
      - Is intercourse happening regularly?
      - Is it occurring during the most fertile times?
      - Assess alcohol and smoking consumption.
      - Acknowledge emotional aspects for couples experiencing infertility.

Teaching Opportunities

  • Recommendations for couples:
      - Engage in intercourse every other day.
      - Target cycle days 7-17 for optimal fertility.
      - Avoid douching or using lubricants which may affect fertility.
      - Retain sperm after intercourse.
      - Initiate prenatal vitamins and adopt a healthy diet.
      - Implement stress alleviation measures.
      - Consider interventions based on individual circumstances.

Assessment of Female Fertility

Ovulatory Factors

  • Female factors account for 25% of infertility cases.

  • Tracking Basal Body Temperature (BBT) is a common method

  • Testing may include:
      - Gonadotropin levels:
        - FSH (on day 3)
        - LH (mid-cycle, indicating ovulation with an LH surge)
      - Progesterone (on day 21)
      - Prolactin levels
      - Thyroid Stimulating Hormone
      - Androgen levels

Cervical Mucus Changes

  • Cervical mucus changes are induced by estrogen as ovulation approaches:
      - Spinbarkheit: Mucus elasticity indicates ovulation.
      - Ferning capacity: Crystallization under a microscope indicates peak fertility.

Characteristics of Ideal Cervical Mucus

  • Ideal mucus for sperm passage should be:
      - Thin
      - Clear
      - Watery
      - Profuse
      - Alkaline

Endometrial Biopsy

  • Provides information on the receptivity of the endometrial lining and progesterone’s effects post-ovulation.

Transvaginal Ultrasound

  • Assesses development of follicles and endometrial thickening.

  • Indicated during ovulation induction, timing for insemination and intercourse, in vitro fertilization (IVF), and early pregnancy.

Uterine Structure and Tubal Patency

  • Hysterosalpingogram: Dye is injected to assess uterine structure and fallopian tube patency.

  • Hysteroscopy: Allows for observation of the uterine cavity’s size, shape, and positioning.

  • Laparoscopy: Visualization for assessing pelvic organs. Can identify endometriosis, adhesions, pelvic inflammatory disease, tumors, and cysts.

Assessment of Male Fertility

Key Considerations

  • Varicocele: Dilation of scrotal veins.

  • Testicular atrophy: May result from prior illness.

  • Absence of vas deferens: A congenital condition.

Semen Analysis Factors

  • Important values include:
      - Volume: Greater than 2 ml
      - pH: 7 to 8
      - Sperm Count: Greater than 20 million/ml
      - Liquefaction: Complete within 1 hour
      - Motility: At least 50% of sperm should move forward
      - Normal Forms: 30% or greater should have normal morphology

Terminology Related to Male Infertility

  • Oligospermia: Low concentration of sperm in semen.

  • Azoospermia: Impaired or non-existent sperm production.

  • Antisperm antibodies: May be present due to impairment of the blood/testes barrier.

Methods of Managing Infertility

Pharmacologic Agents

  • Clomiphene (Clomid):
      - Induces ovulation by stimulating the hypothalamus to produce more FSH and LH (route: PO).
      - Can be combined with LH indicators or BBT tracking, and timed intercourse, or intrauterine insemination.
      - Increased risk of multiple gestations.

  • Gonadotropins: (Examples: Repronex, Menopur, Follistim, Gonal-F)
      - Administered via IM/SQ injection.
      - Contains FSH and LH, used for anovulatory women with low or normal levels and those who did not conceive with Clomid.
      - Patients must be closely monitored for hyperstimulation and multiple pregnancies; ultrasound to monitor follicle development.
      - hCG: Administered to trigger ovulation when follicles are mature, with intercourse timing advised 24-36 hours later.

  • Progesterone:
      - Administered post-hCG to increase endometrial receptivity for implantation.
      - Important in cases of luteal phase defect, which may arise from poor follicle maturation, corpus luteum demise, or inadequate endometrial response to progesterone.
      - Low progesterone levels are often associated with FSH during the proliferative phase.

  • Bromocriptine (Parlodel):
      - Inhibits the secretion of prolactin from the pituitary.
      - Used in anovulatory patients with elevated prolactin levels impairing FSH and LH production.
      - Considered teratogenic with potential side effects such as nausea, diarrhea, dizziness, headache, and fatigue.

  • Insulin Sensitizing Agents: (Example: Metformin (Glucophage))
      - Used to treat women with Polycystic Ovarian Syndrome (PCOS), often linked with hyperinsulinemia.

  • Endometriosis Management:
      - Danocrine (Danazol) suppresses ovulation and menstruation, allowing for atrophy of endometrial tissue.
      - Oral contraceptives can also be effective.

Overview of Pharmacological Treatments

  • Clomiphene (Clomid): Stimulates and releases eggs through hypothalamic stimulation.

  • Gonadotropins: Directly stimulate follicle development.

  • hCG: Triggers ovulation.

  • Progesterone: Prepares the endometrial lining and maintains pregnancy.

  • Bromocriptine (Parlodel): Inhibits prolactin secretion, enabling FSH and LH production.

  • Danocrine (Danazol): Treats endometriosis.

  • Metformin (Glucophage): Controls hyperinsulinemia in PCOS patients.

Therapeutic Insemination

  • Placement of sperm at the cervical opening; can occur naturally or with ovarian stimulation depending on infertility causes.

  • Rationale:
      - Male factors: low sperm count, impaired motility, abnormal morphology.
      - Female factors: inhospitable cervical mucus or cervical stenosis.

Donor Sperm

  • Utilized for issues related to sperm quality or quantity, single women, or in same-sex couples.

  • Ethical/Legal Concerns:
      - Need for informed consent from all parties involved.
      - Medical and infectious disease screening to prevent transmission of genetic defects and STIs.
      - Regulations on the number of pregnancies per donor and storage practices, including freezing and quarantining for six months.

Assisted Reproductive Technology (ART)

In Vitro Fertilization (IVF)

  • After infertility medication, eggs are extracted and fertilized with sperm in a lab; embryos are transferred into the uterus 1-5 days later.

  • Rationale includes addressing issues related to tubal, cervical, male factors, or immunological infertility.

  • IVF is often emotionally and financially burdensome.

Embryo Cryopreservation

  • Storage of excess embryos for future use.

  • Placing 3-4 embryos offers the best chance of achieving pregnancy.

  • Legal/Ethical Questions:
      - Concerns regarding the placement of excessive embryos, legal custody of embryos, implications of donor situations in the event of death or divorce, storage duration, and handling of remaining embryos (donation options).

Gamete Intrafallopian Transfer (GIFT)

  • Eggs collected with ultrasound guidance; eggs and sperm are transferred directly into the fallopian tube.

  • This may be culturally or religiously preferable compared to IVF.

Zygote Intrafallopian Transfer (ZIFT)

  • Similar to GIFT but involves fertilizing eggs in the laboratory, then transferring zygotes to the fallopian tube.

  • Differences from IVF include fertilization context and procedural timing.

Donor Oocytes

  • Use of donor eggs in cases of ovarian failure, surgical removal, advanced maternal age, chemotherapy impact, genetic disorders, or oocyte defects.

  • Donor eggs may be sourced from known or anonymous donors, requiring extensive genetic and medical screening before use.

  • Fertilized with the partner’s sperm and placed in the uterus, with hormonal support until the placenta develops.

Sperm Sorting

  • Sperm sorting by desired sex for insemination or IVF, motivated by chromosomal concerns or family planning preferences.

Gestational Carrier

  • A woman contracted to carry a pregnancy genetically not her own, often due to absence of a uterus or other medical conditions preventing successful pregnancy.

  • Surrogacy: Involves both gestational and oocyte donation.

Intracytoplasmic Sperm Injection (ICSI)

  • Specialized procedure utilized when sperm quality or morphology is concerning or genetic issues exist.

  • Also indicated if previous conventional IVF attempts were unsuccessful.

Adoption

  • A viable solution for couples facing infertility.

  • The adoption process can be lengthy and costly and is often an emotional journey for those involved.

Conclusion

  • Comprehensive management of infertility is multifaceted, involving thorough assessment, various treatment methodologies, and addressing ethical and legal concerns surrounding assisted reproductive technologies and related options.