INFERTILITY - assignment
INTRODUCTION
Generally
world wide it is estimated that one is seven couples have problems of
conceiving. Conception depends on the fertility potential of both male and
female partner.
INFERTILITY
Definition
Infertility
is defined as a failure to conceive within one or more years of regular
unprotected intercourse.
They are two types of infertility
Ø Primary Infertility
It denotes couples who have never been
able to conceive.
Ø Secondary Infertility
It is the inability to get pregnant for
one year after last delivery or abortion in the absence of contraceptive use.
Incidence
Ø Generally
world wide it is estimated that one in seven couple have problems conceiving.
Ø Eighty
percent of couples achieve conception within one year of having regular
intercourse with adequate frequency (4-5 times a week)
Ø Another
10 percent will achieve the objective by the end of second year.
Ø About
10 percent remain infertile by the end of third year.
CAUSE OF INFERTILITY
Conception depends
on the fertility potential of both male and female partner. For infertility male
factor contribution is about 30 to 40 percent and female factor about 40 to 50 percent
and combines factor about 10 to 15 percent.
MALE
FACTORS THAT CAUSE INFERTILITY
1.
DEFECTIVE SPERMATOGENESIS
Supermatogenesis
and sperm maturation need a high androgenic environment. Spermatogenesis is
predominantly controlled by the genes on the ‘y’ chromosome. The process of spermatogenesis
takes approximately 74 days for completion. Additional 12 to 24 days are needed
for spermatozoa to travel the epididymis. The cause of defective spermatogenesis
are
Ø Congenital
Ø Undescended
testes is a congenital condition
Ø Hypospadias
causes failure to deposit sperm in the vagina
Ø Thermal
factor
The
scrotal temperature has to be 10 and 20F less than the
body temperature.
Ø Loss
of sperm mortility
Ø Immunological
factor
Antibodies against spermatozoa surface
antigens may cause infertility
Ø Genetic
Common chromosomal abnormality, in
azoospermic male is kleinfleters syndrome.
Ø Iatrogenic
Radiation, cytotoxic drugs,
nitrofuranton, b
blockers, antihypertensive, anticonvulsants and antidepressants drugs likely to
hinder spermatogenesis.
Ø Endocrine
Factors
FSH level is seen raised in idiopathic
testicular failure.
2.
Obstruction of the Efferent Ducts
The
efferent ducts may be obstructed by tubercular infection or due to surgical
trauma during vasectomy or herniorraphy.
3.
Failure to deposit sperm in the Vagina
Ø Erectile
dysfunction
Ø Hypospadias
Ø Absence
of ejaculation
4.
Errors in Seminal Fluid
Ø Unusually
high or low volume of ejaculate (normal volume is 2ml or more)
Ø Low
fructose content
Ø High
prostaglandin content
Ø Undue
viscosity
CAUSES
OF FEMALE INFERTILITY
1.
Ovarian Factors
Ø Anovulation
or Oligo-ovulation
Ovarian activity depends on gonadotrophins
which are related to the release GNRH from hypothalamus. Disturbance of these
may result in anovuation.
2.
Tubal and Peritoneal Factors
Tubal and
peritoneal factors are responsible for about 30 to 40 percent of cases of
female infertility. These include;
Ø Peritubal
adhesions
Ø Endosalpingeal
damage
Ø Previous
tubal surgery
Ø Tubal
spasm
Ø Salpingitis
3.
Uterine Factors
These
include factors that interfere with reception and nidation of fertilized ovum
(unfavourable endometrium).
4.
Cervical Factors
Ineffective
sperm penetration due to following factors
Ø Chronic
cervicilis
Ø Presence
of anti sperm antibodies
Ø Second
degree uterine prolapse
Ø Scanty
vaginal mucus
Ø Congenital
elongation of cervix
5.
Vaginal Factors
Ø Atresia
Ø Septum
Ø Narrow
introitus
Combined
Factors
These
include presence of factors both in female and male factors causing infertility
Ø Age
of wife beyond 35 years and advancing age in men
Ø Infrequent
intercourse (less than 4-5 per week) during fertile period (around ovulation)
Ø Anxity
and apprehension
Ø Use
of lubricants during intercourse which may be spermicidal.
Ø Immunological
factors (antisperm antibodies)
Investigation
of Female
History
Ø History: Age, duration of marriage, history of
previous marriage with proven infertility if any.
Ø Medical
History: Tuberculosis, pelvic inflammatory disease, diabetes.
Ø Surgical
History: Abdominal or pelvic surgery that can cause peritubal adhesions.
Ø Menstrual
History: Hypomenorrhea or oligomenorrhea
Ø Previous
obstetric history
Ø Contraceptive
practices: Used of IUCD that have chance to produce PID
Ø Sexual
Problems: Dyspareunia and loss of libido.
Examination
Ø General
Examination: Obesity or marked reduction in weight, abnormal distribution of
hair, and underdevelopment of secondary sex characteristics.
Ø Systemic
Examination: Hypertension, organic heart
disease etc
Ø Gynecologic
Examination: To look for vaginal infection uterine size, shape, position and mobility.
Ø Speculum
Examination: For presence of cervical discharge, which if present needs to be
tested for infection.
DIAGNOSTIC
EVALUATION
Ø Menstrual
History
Look for evidences of ovulation such as;
o
Regular, normal menstrual loss between the
ages of 20-35.
o
Midmenstrual bleeding or paid or excessive
mucoid vaginal discharge.
o
Features of primary dysmenorrhoea
Ø Sonography:
Serial sonography during midcylce can precisely measure the graafian follicle
just prior to ovulation.
Ø Laparoscopy
Ø Insuffiation Test: It is done to see the patency of
fallopian tubes.
Treatment
The aims of
all treatment with assisted conception techniques is to promote the chances of
fertilization and subsequent pregnancy by bringing the sperm and egg close to
each other.
1.
Ovulation Induction
Ovulation
disorders are three groups
Ø Group
I : Hypothalamic Pituitary Failure
Ø Group
II: Hypothalamic Pituitary Disfunction
Ø Group
III: Ovarian Failure
Ø Clomifene
citrate and tamoxifen are referred to as anti-oestrogens and are a first line
treatment for Group II hypothalamic pituitary disfunction.
Ø Women
with clomifena resistant polycystic ovarian syndrome can be treated with
gonadotrophins.
Ø Dopamine
against such as bromoptine and cabergoline are safe and effective treatment for
women with ovulatory disorders due to hyperprolactinaemia.
2.
Intrauterine Insemination
IUI is
indicated as a first line management where there are problems such as hostile
cervical mucus, antisperm, antibodies or male fertility problems such as a low
sperm count it is also useful for cases
of unexplained infertility.
3.
Invitro Fertilization/Embryo Transfer (IVF/ET)
Invitro
fertilization describes the laboratory technique where fertilization occurs
outside the body. IVF is indicated in
cases where the female partners has uterine tube occlusion, endometriosis or
cervical mucus problem.
4.
Intracytoplasmic Sperm Injection
It is a
highly specialized variant of IVF treatment that involves the injection of a
single sperm into the cytoplasm of an egg with a fine glass needle. It is
useful technique when sperm quality is poor and in azoospermic men sperm can be
obtained surgically from the epididymis or extracted from the testis itself.
5.
Gamete Intra Fallopian Transfer (BIFT) and
Zygote
Infrafallopian Transfer (ZIFT)
These are
laparoscopic techniques that offer little clinical advantage over invitro fertilization.
MANAGEMENT
OF INFERTILITY
Management
of infertility would depend upon the cause identified, duration and age of the
couple, especially the female.
General
Instructions:
Ø Body
weight: Over weight or under weight
Ø Excess
use of smoking and alcohol should be avoided
Ø Ideal
coital frequency: Intercourse on multiple during the fertile window period.
Ø Avoidance
of lubricants
Ø The
use of fertility impairing medications should be avoided by both partners.
Ø Psychological
support should be offered as the couple may face significant stress and sadness
as the investigations and consultations progress.
MANAGEMENT
OF MALE INFERTILITY
General
Care
Ø Improvement
of general health
o
Reduction of weight in obese
o
Avoidance of alcohol and heavy smoking
o
Avoidance of light and warm under garments
Ø Avoiding
medications that interfere with spermatogenesis
Ø Special
treatments for causes identified such as
o
Intrauterine insemination (IUI)
o
In vitro fertilization (IVF)
o
Intracytoplasmic sperm injection (ICSI)
o
Artificial insemination with donor sperm (AID)
Ø Surgical
Treatment
o
Correction of hydrocele
o
Vasoepididymostomy
Management
of Female Infertility
Ø Ovulatory
Dysfunction
o
Induction of ovulation using drug such as
citrate letrozole etc
o
Correction of biochemical abnormality
o
Substitution therapy: Thyroxin for
hypothyroidism, anti diabetic drugs for diabetes mellitus.
Ø Surgery
o
Laproscropic ovarian drilling (LOD)
o
Surgical removal of functioning ovarian or
adrenal tumor
o
Cannulation and balloon tuboplasty for block
in tube
o
Salpingostomy to create an opening in tube in
a completely occuluded tube.
NURSING
MANAGEMENT
Ø Nurses
meet couples seeking help for treatment of infertility in special centers
clinics where such services are available.
Ø Assessing,
educating, counselling to the couples about the infertility tests and
procedures.
Ø Provide
psychological support to the couple who undergo infertility treatment
Ø The
nurse should help the couples to understand and accept that the evaluation and
treatment for infertility will be stressful and involve the both partners
throughout the process.
Ø The
nurse should take the detailed medical and family history from each partners.
Ø During
the period of therapy the couples need to avoid smoking, good diet, exercises,
maintain health and take folic acid supplement if prescribed.
TYPES
OF OPERATION
Ø Anterior
Colporrhaphy
Ø Colpoperineorrhaphy
Ø Fothergill’s
Operation
Ø Vaginal
Hysterectomy
CONCLUSION
The
management of the infertility should be take place in the dedicated infertility
clinic by trained staff. There are two type of infertility primary infertility
and secondary infertility. In many cases 30% of couples get pregnant after
simple history taking, examination, investigation and counselling without
starting any treatment. By the unnecessary treatment of husband and wife will
harm or affect the future fertility.
BIBLIOGRAPHY
Ø A
Textbook of Standards of Practice for Integrated MCH/RH Service, 1st
Edition, June 2005.
Page No. 385-392
Ø A
Textbook of Myles for Midwives, 14th Edition
Ø A
Comprehensive Textbook for Midwifery and Gynaecological Nursing.
Page No. 716-724
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