Nursing Care and Fertility: Page-by-Page Notes (Pages 102-148)

Page 102

Nursing Care of the Family Having Difficulty Conceiving a Child

• Overview: The transcript begins with an introduction to nursing care for families dealing with difficulty conceiving. It emphasizes understanding, support, and the impact on family dynamics during infertility assessment and treatment.

Page 103

Infertility and Subfertility: Definitions and Impact

• Infertility: describes the inability to conceive a child or sustain a pregnancy to birth.
• Subfertility: more commonly used today; describes reduced fertility that may require assistance.
• Subfertility assessment: involves many months and many tests; potential to affect a couple’s self-image, self-esteem, and lifestyle.

Page 104

Subfertility, Primary vs Secondary, and Contributing Factors

• Subfertility is said to exist when pregnancy has not occurred after at least $1$ year of unprotected coitus.
• Primary subfertility: no previous conceptions.
• Secondary subfertility: there has been a previous viable pregnancy, but the couple cannot conceive now.
• Age is related to subfertility.
• Sterility: the inability to conceive due to a known condition (e.g., absence of a uterus).
• Causes are multifactorial.
• Coital frequency effects:
  • Daily coitus with the hope of rapid impregnation may hinder conception.
  • Too-frequent coitus can lower a man’s sperm count to a less-than-optimal level.
  • Some couples try to time sex using temperature charts, which can govern daily life.

Page 105

Time-Honored Suggestions to Aid Conception (Part I)

• Determine ovulation timing via basal body temperature (BBT) or analysis of cervical secretions; plan sexual relations for every other day around ovulation.
• Frequent intercourse may stimulate sperm production, but men need recovery time after ejaculation to maintain adequate sperm count; coitus every other day during the fertile period is often recommended.
• The male-superior position is considered favorable for conception as it places sperm closer to the cervical opening.
• Deep penetration is encouraged so ejaculation deposits sperm near the cervix.
• Elevating the woman’s hips on a small pillow can help deposit sperm near the cervix.
• After ejaculation, the woman can remain on her back with knees drawn up for at least $20$ minutes to help keep sperm near the cervix.

Page 106

Time-Honored Suggestions to Aid Conception (Part II)

• Avoid douching or lubricants before or after intercourse to keep vaginal pH unaltered and maintain sperm mobility.
• Diet: high in slowly digested carbohydrates, low in saturated/trans fats, and moderate in protein.
• Body mass index (BMI): maintain $18.5 \le \mathrm{BMI} \le 24.9$.
• Exercise: about $30$ minutes per day to stabilize blood glucose and insulin levels.
• Engage in a joint activity (e.g., bowling, ballroom dancing) to create a shared focus away from baby planning; supports a positive outlook during months without conception.

Page 107

Fertility Assessment Timing

• Fertility assessment is not advised before age $18$ or after $45$.

Page 108

Fertility Testing: Basic Questions and Tests

• Basic fertility testing aims to answer three questions:
  1. Is there sperm of good quality and number available?
  2. Are ova (eggs) available (i.e., is the woman ovulating)?
  3. Is it possible for sperm and egg to meet in a receptive environment?
• Three commonly used tests:
  • Semen analysis in men
  • Ovulation monitoring in women
  • Tubal patency assessment in women

Page 109

Factors That Cause Male Subfertility

• Disturbance in spermatogenesis (sperm production).
• Inadequate production of FSH and LH in the pituitary (hormones that stimulate sperm production).
• Obstruction in the seminiferous tubules, ducts, or vessels (impeding sperm movement).
• Qualitative or quantitative changes in seminal fluid (affecting sperm motility).
• Autoimmunity that immobilizes sperm.
• Problems in ejaculation/deposition, preventing sperm from reaching near the cervix.
• Chronic or excessive exposure to X-rays or radioactive substances, general ill health, poor diet, and stress, all of which may impair sperm production.

Page 110

Limited Sperm Count: Definitions and Contributing Factors

• Sperm count definition: the number of sperm in a single ejaculation or in a milliliter of semen.
• Normal minimum values include:
  • $33 \text{ to } 46 \times 10^6\ \text{sperm/mL}$ or $50 \times 10^6\ \text{sperm per ejaculation}$
  • $\ge 50\%$ motile sperm
  • $\ge 30\%$ morphologically normal sperm
• Congenital abnormalities can lower sperm count; cryptorchidism (undescended testes) is a cause if not repaired; a varicocele (enlargement of the internal spermatic vein) can increase testicular temperature and disrupt spermatogenesis.

Page 111

Temperature and Testicular Function

• Spermatozoa require a slightly lower temperature than core body temperature for optimal motility; testes are suspended in the scrotum for this reason.
• Increased scrotal heat can lower sperm count. Examples:
  • Chronic infections (e.g., TB, recurrent sinusitis) may raise scrotal temperature.
  • Occupational/behavioral factors: desk jobs or long daily drives can lower counts compared to ambulatory men.
  • Frequent use of hot tubs or saunas can lower sperm counts.

Page 112

Other Contributors to Impaired Sperm Production

• Past trauma to the testes; surgery near the testes affecting circulation.
• Endocrine imbalances (thyroid, pancreas, pituitary).
• Drug use or excessive alcohol use.
• Environmental factors (exposure to X-rays or radioactive substances).
• Protective measures: workers exposed to radiation should have testicular protection; during pelvic X-rays, use a protective lead shield for testes.

Page 113

Testing for Sperm Number and Pituitary Hormones; Semen Analysis Details

• Pituitary hormones: blood test to assess levels of FSH and LH.
• Typical male phenotype with normal secondary characteristics often correlates with normal fertility; however, limitations can occur even with normal appearance.
• Semen analysis (WHO-based expectations, 2010):
  • Minimum semen volume: $1.4 \text{ to } 1.7\ \text{mL}$ per ejaculation
  • Minimum sperm concentration: $33 \text{ to } 46\times 10^6/\text{mL}$
  • Process: abstinence for 2$-$4\ days prior to analysis; ejaculation via masturbation into a clean container or a sperm-friendly condom (without spermicide); count and microscopic examination within 1\text{ hour}$of ejaculation.</li></ul></li> </ul> <h3 id="page114">Page 114</h3> <p>Semen Analysis: Guidelines for Accuracy</p> <ul> <li>Abstinence period: about$3$days.</li> <li>Specimen handling:<ul> <li>Use a clean, dry container with a secure lid.</li> <li>Collect as close as possible to usual time of sexual activity.</li> <li>Avoid lubricants during collection.</li> <li>Securely close the container and record collection time.</li> <li>Transport at body temperature (e.g., carry close to the chest).</li></ul></li> <li>Repetition: analysis may be repeated after$2$-$3\ months$due to ongoing sperm production;$30$-$90\ days$are needed for new sperm to mature.</li> <li>Home options: self-test kits for sperm motility are available online.</li> <li>If there is a vas deferens obstruction, sperm can be obtained by testes biopsy.</li> </ul> <h3 id="page115">Page 115</h3> <p>Sperm Penetration, Antisperm Antibody Testing, and Therapy to Increase Count/Motility</p> <ul> <li>Sperm Penetration Assay and antisperm antibody testing evaluate whether sperm can penetrate an ovum after reaching it (sperm must be mobile enough to traverse vagina, uterus, and fallopian tubes).</li> <li>Therapy to increase count/motility:<ul> <li>If sperm count is low but present, abstain from intercourse for$7$-$10\ days$to boost count.</li> <li>Ligation of a varicocele (if present) and lifestyle changes (avoid recreational marijuana use, wear looser clothing, avoid prolonged sitting, avoid hot baths) can reduce scrotal heat and improve count.</li></ul></li> </ul> <h3 id="page116">Page 116</h3> <p>Obstruction or Impaired Sperm Motility</p> <ul> <li>Scenario: adequate sperm production but obstruction along the path (seminiferous tubules, epididymis, vas deferens, ejaculatory duct, or urethra) prevents passage.</li> <li>Diseases causing obstruction: mumps orchitis, epididymitis, gonorrhea, ascending urethral infections can form adhesions.</li> <li>Other anatomic factors: epispadias (dorsal urethral opening), Peyronie disease (curved penis) can misplace deposition; extreme obesity may interfere with deposition efficiency.</li> <li>Congenital stricture of a spermatic duct may occur. Benign prostatic hypertrophy (BPH) begins around age$50$in many men.</li> </ul> <h3 id="page117">Page 117</h3> <p>Ejaculation Problems</p> <ul> <li>Erectile dysfunction (previously called impotence) can result from psychological issues, certain diseases (e.g., stroke, diabetes, Parkinson’s), some antihypertensive medications, or discontinuation of finasteride.</li> <li>Premature ejaculation: ejaculation before penetration; often linked to psychological factors; more common in adolescents and improves with experience.</li> <li>ED can be challenging to address when linked to stress.</li> </ul> <h3 id="page118">Page 118</h3> <p>Testing and Therapy for Ejaculation Concerns</p> <ul> <li>Identification: sexual history helps identify ejaculation concerns.</li> <li>Treatments for ED: psychological/sexual counseling; phosphodiesterase inhibitors (e.g.,$sildenafil\ (Viagra)$or$tadalafil\ (Cialis)$).</li> <li>Premature ejaculation: dapoxetine (short-acting SSRI) taken about$1\ hour$before planned coitus shows good results.</li> </ul> <h3 id="page119">Page 119</h3> <p>Factors That Cause Female Subfertility</p> <ul> <li>Anovulation (absence of ovulation) is the most common cause of subfertility in women; possible etiologies include:<ul> <li>Turner syndrome (hypogonadism) with hormonal imbalance</li> <li>Hypothyroidism</li> <li>Ovarian tumors or polycystic ovary syndrome (PCOS)</li></ul></li> <li>Chronic or excessive exposure to X-rays or radioactive substances, general ill health, poor diet, and stress can contribute to poor ovarian function.</li> <li>Nutrition, body weight, and exercise influence ova production by affecting blood glucose/insulin balance.</li> </ul> <h3 id="page120">Page 120</h3> <p>Testing for Anovulation: Ovulation Monitoring</p> <ul> <li>Serum progesterone measurement during the luteal phase (approximately day$21$to$28$) is the fastest way to assess ovulation: elevated progesterone implies corpus luteum formation and ovulation.</li> <li>Basal body temperature (BBT) charting for at least$4$months is a low-cost method to determine ovulation patterns.</li> </ul> <h3 id="page121">Page 121</h3> <p>Ovulation Determination by Test Strip</p> <ul> <li>Woman dips an ovulation test strip into a midmorning urine specimen and compares color change to kit instructions; tests are available over the counter and are easy to use.</li> </ul> <h3 id="page122">Page 122</h3> <p>Therapy for Anovulation</p> <ul> <li>Gonadotropin-releasing hormone (GnRH) therapy is a possibility to stimulate the pituitary to secrete more FSH and LH.</li> <li>Clomiphene citrate (Clomid) or letrozole (Femara) may be used to stimulate ovulation.</li> <li>CLOMIPHENE CITRATE (CLOMID):<ul> <li>Action: an estrogen agonist that binds to estrogen receptors, decreasing available estrogen receptors and falsely signaling the hypothalamus to increase FSH and LH secretion, resulting in ovulation.</li> <li>Pregnancy category:$X$</li></ul></li> </ul> <h3 id="page123">Page 123</h3> <p>Tubal Transport Problems</p> <ul> <li>Tubal transport problems occur due to scarring in the fallopian tubes, typically from chronic salpingitis (chronic pelvic inflammatory disease).</li> <li>Complete tubal obstruction is a chief problem if a prior tubal ligation is being reconsidered for pregnancy.</li> <li>Pelvic inflammatory disease (PID) is an infection of the uterus, fallopian tubes, ovaries, and supporting structures.</li> </ul> <h3 id="page124">Page 124</h3> <p>Testing for Tubal Patency</p> <ul> <li>Imaging modalities include ultrasound or X-ray imaging and direct visualization by a hysteroscope.</li> </ul> <h3 id="page125">Page 125</h3> <p>Sonohysterosalpingogram (SHTG)</p> <ul> <li>A sonohysterosalpingogram is a sonographic examination of the fallopian tubes and uterus using a contrast agent introduced into the uterus via a narrow catheter through the cervix, followed by intravaginal scanning.</li> <li>If tubes are patent, they fill with contrast and appear on the ultrasound screen.</li> <li>Contraindications: infection of the vagina, cervix, or uterus.</li> <li>Scheduling: typically just after menstruation when pregnancy is unlikely.</li> </ul> <h3 id="page126">Page 126</h3> <p>Hysterosalpingogram (HSG)</p> <ul> <li>HSG uses radiopaque contrast and X-ray to reveal fallopian tubes.</li> <li>More contrast is used than in sonohysterosalpingography; the pressure can sometimes break tubal adhesions (therapeutic as well as diagnostic).</li> <li>Scheduling: after menses due to pregnancy risk.</li> </ul> <h3 id="page127">Page 127</h3> <p>Transvaginal Hydrolaparoscopy</p> <ul> <li>Procedure steps:<ul> <li>Local anesthetic block (paracervical).</li> <li>Hysteroscope inserted through the vagina, cervix, into the cul-de-sac of Douglas into the peritoneal cavity.</li> <li>About 200 mL of normal saline is instilled to move bowel away, allowing assessment of posterior uterus, ovaries, and fallopian tubes.</li> <li>Tubal patency can be evaluated by injecting a small amount of dye through the cervix and observing exit from the fimbrial end.</li> <li>Fluid is drained at the end; incision heals without stitches.</li></ul></li> </ul> <h3 id="page128">Page 128</h3> <p>Therapy for Lack of Tubal Patency and Alternatives</p> <ul> <li>Therapeutic options to improve tubal patency include:<ul> <li>Diathermy or steroids to reduce adhesions.</li> <li>Hysterosalpingography (dye instillation under X-ray) to attempt adhesion breakage.</li> <li>Canalization of tubes and microsurgical repair.</li> <li>Laparoscopy or laser surgery to remove endometriosis nodules if tubes are fixed.</li> <li>Reopening ligated fallopian tubes surgically is possible.</li></ul></li> </ul> <h3 id="page129">Page 129</h3> <p>Uterine Concerns</p> <ul> <li>Uterine factors in subfertility include:<ul> <li>Fibroids (leiomyomas) that block tubal openings into the uterus or reduce implantation space (rare cause).</li> <li>Congenitally deformed uterine cavity limiting implantation sites (rare).</li> <li>Endometriosis: implantation of endometrium outside the uterus.</li></ul></li> </ul> <h3 id="page130">Page 130</h3> <p>Testing for Uterine Concerns</p> <ul> <li>Hysteroscopy: visual inspection of the uterus via a hysteroscope inserted through the vagina, cervix, into the uterus; assesses adhesions, malformations, fibroids, polyps.</li> <li>Chlamydia screening is performed prior to the examination to reduce infection risk.</li> </ul> <h3 id="page131">Page 131</h3> <p>Uterine Endometrial Biopsy</p> <ul> <li>Purpose: to reveal endometrial problems (e.g., luteal phase defect).</li> <li>Interpretation: if the endometrium resembles a corkscrew pattern (progesterone-dominated endometrium) in the second half of the cycle, ovulation has occurred.</li> <li>Timing: biopsy is typically performed on day$25$or$26$of a typical 28-day cycle, a few days before expected menses.</li> <li>Procedure note: there may be a moment of sharp pain during biopsy from the uterine wall.</li> </ul> <h3 id="page132">Page 132</h3> <p>Laparoscopy: Visualizing the Pelvic Organs</p> <ul> <li>Laparoscopy involves inserting a thin, hollow, lighted tube (laparoscope) through a small abdominal incision (usually beneath the umbilicus) to examine fallopian tubes and ovaries.</li> <li>Not commonly done unless uterosalpingography results are abnormal; it requires general anesthesia due to pain.</li> <li>Scheduling: typically during the follicular phase of the cycle.</li> <li>Positioning: steep Trendelenburg to move reproductive organs downward.</li> <li>CO2 insufflation is used to expand the abdominal cavity.</li> <li>Post-procedure: abdominal bloating from CO2 is common.</li> <li>During laparoscopy, dye can be injected into the uterus to assess tubal patency (if tubes are patent, dye appears in the peritoneal cavity).</li> </ul> <h3 id="page133">Page 133</h3> <p>Therapy for Uterine Concerns</p> <ul> <li>Luteal phase defect: progesterone vaginal suppositories can be started on the third day of the temperature rise and continued for 6 weeks (or until menstruation if pregnancy does not occur).</li> <li>Myoma (fibroid) or intrauterine adhesions: myomectomy or removal of adhesions may be scheduled.</li> </ul> <h3 id="page134">Page 134</h3> <p>Assisted Reproductive Techniques (ART): Overview</p> <ul> <li>Alternative Insemination (also called intrauterine insemination or intracervical insemination):<ul> <li>Sperm from a masturbatory sample is placed into the female reproductive tract at ovulation via a cannula.</li> <li>Possibilities: intracervical insemination (ICI) or intrauterine insemination (IUI) at the time of predicted ovulation.</li> <li>Donor sperm or partner sperm can be used when needed (e.g., male partner azoospermia, poor motility, or female cervical factors).</li></ul></li> </ul> <h3 id="page135">Page 135</h3> <p>In Vitro Fertilization (IVF) and Donor Ova</p> <ul> <li>IVF is often used when the woman has obstructed or damaged fallopian tubes.</li> <li>Process: one or more mature oocytes are retrieved from the ovary via laparoscopy and fertilized by sperm in a laboratory.</li> <li>About$40$hours after fertilization, the fertilized ova (now zygotes) are inserted into the uterus for implantation.</li> <li>Donor oocytes can be used if the woman does not ovulate or carries a gender-linked disease she does not want to pass on.</li> </ul> <h3 id="page136">Page 136</h3> <p>Surrogate Embryo Transfer</p> <ul> <li>Surrogate embryo transfer is for a woman who does not produce ova.</li> <li>Process: donor oocyte is fertilized with partner’s sperm (or donor sperm) and the embryo is transferred to the recipient’s uterus.</li> <li>Synchronization of cycles is achieved with gonadotropic hormones.</li> <li>If pregnancy occurs, it progresses like a normal pregnancy in the recipient.</li> </ul> <h3 id="page137">Page 137</h3> <p>Preimplantation Genetic Diagnosis (PGD)</p> <ul> <li>Retrieval of oocytes and in vitro fertilization allow genetic analysis of sperm and oocytes.</li> <li>After IVF and ZIFT, DNA can be examined for abnormalities (e.g., Down syndrome, hemophilia).</li> <li>Intrauterine transfer and donor insemination can involve sex selection via genetic testing.</li> </ul> <h3 id="page138">Page 138</h3> <p>Alternatives to Childbirth</p> <h3 id="page139">Page 139</h3> <p>Surrogate Mothers</p> <ul> <li>A surrogate mother agrees to carry a pregnancy to term for subfertile or LGBT couples.</li> <li>Ova may be provided by the donor or by the intended mother; sperm may be from the partner or a donor; donors can be paid or reimbursed for expenses.</li> <li>Surrogates may be friends, family, or referred via agencies or attorneys.</li> </ul> <h3 id="page140">Page 140</h3> <p>Adoption</p> <ul> <li>Adoption is a viable alternative for subfertile and LGBT couples, or for individuals with genetic or health concerns that complicate pregnancy.</li> </ul> <h3 id="page141">Page 141</h3> <p>Child-Free Living</p> <ul> <li>Child-free living is an option for both fertile and subfertile couples.</li> <li>It can be fulfilling, allowing more time for personal goals and contributing to society through work, travel, or hobbies.</li> <li>It can provide freedom from pregnancy-related expenses and scheduling.</li> </ul> <h3 id="page142">Page 142</h3> <p>Advantages and Considerations of Child-Free Living</p> <ul> <li>May permit more time for careers, travel, and personal pursuits.</li> <li>Family involvement: opportunities to contribute through family connections, volunteer work, or local schools and community programs.</li> <li>Some couples prefer child-free living due to concerns about overpopulation.</li> <li>Research indicates married couples with children may report lower happiness due to costs and responsibilities; child-free couples may report higher marital satisfaction in some cases.</li> </ul> <h3 id="page143">Page 143</h3> <p>Stages of Fetal Development: Germinal Stage (Weeks 1–2)</p> <ul> <li>Fertilization: sperm and egg unite to form a zygote.</li> <li>Cleavage: rapid cell division as the zygote travels down the fallopian tube.</li> <li>Blastocyst formation: a hollow ball of cells forms.</li> <li>Implantation: around days$6$–$10$, the blastocyst embeds into the uterine wall.</li> </ul> <h3 id="page144">Page 144</h3> <p>Stages of Fetal Development: Embryonic Stage (Weeks 3–8)</p> <ul> <li>This is the organogenesis period (critical for organ development).</li> <li>Week 3–4: neural tube formation (will become brain and spinal cord).</li> <li>Heart begins beating around Day$22$.</li> <li>Week 5–6: limb buds appear; brain, eyes, ears, and other organs begin forming.</li> <li>Week 7–8: facial features become more defined; fingers and toes form; major internal organs are present in rudimentary form.</li> <li>High risk of congenital anomalies if exposed to teratogens during this stage.</li> </ul> <h3 id="page145">Page 145</h3> <p>Stages of Fetal Development: Fetal Stage (Week 9 to Birth)</p> <ul> <li>Growth, maturation, and refinement of organs characterize this stage.</li> <li>First Trimester (Weeks 9–12): sex organs differentiate; fetus begins moving (not felt by mother yet); kidneys and liver begin functioning.</li> <li>Second Trimester (Weeks 13–26): fetal movements felt by mother around Weeks$18$–$20$(quickening); skin is translucent and covered with lanugo; eyebrows and eyelashes form; heartbeat audible via Doppler.</li> <li>Third Trimester (Weeks 27–40): rapid brain development; lungs mature with surfactant production around Weeks$28$–$32$; weight gain accelerates; by Week$37$, the baby is considered full-term.</li> </ul> <h3 id="page146">Page 146</h3> <p>Summary Table: Stages and Key Events</p> <ul> <li>Germinal: Weeks$1$–$2$— Fertilization, implantation, cleavage, blastocyst formation.</li> <li>Embryonic: Weeks$3$–$8$— Organogenesis; heartbeat begins.</li> <li>Fetal (Early): Weeks$9$–$20$— Organ maturation, movement begins.</li> <li>Fetal (Late): Weeks$21$–$40$$ — Growth, lung maturation, full-term prep.
  • Note: A concise summary table consolidates these stage names, weeks, and key events.

  Page 147

  Germinal, Embryonic, and Fetal Milestones (Visual Summary)

  • A visual alignment showing Germinal, Embryonic, and Fetal stages with timelines and corresponding key structures (e.g., midbrain, forebrain, hindbrain) across Weeks 0–40.

  Page 148

  End of Transcript

  • The document ends with a closing note referencing the source layout (WPS Office) and does not introduce new substantive content.