The management of the infertility should be take place in the dedicated cline by trained staff.

 

Introduction

 

            “A mother’s joy begins when a new life is stirring inside….. When a tiny heart beat is heard for very just time and a playful kick remembers her that she is never alone.

                   According to who, positive reproductive health of a woman is a state of complete physical mental and social well being and not merely absence of diseases related to reproductive system and functions.  Conception is a result of Success full fertilization of female egg by the sperm. Hence the couple should be counseled in devidually and then together because both partners contributed varyingly to the occurrence of the infertile state.

 

Definition

          Infertility is defined as a failure to conceive within one or more years of regular unprotected intercourse

 

Types

·        Primary infertility

            It denotes couple who have never been able to conceive

·        Secondary infertility

            It is the inability to get pregnant for one year after last delivery or abortion in the absence of contraceptive use.

Incidence

·        Generally world wide it is estimated one in seven couple have problems conceiving.

·        Eighty percent of couples achieve conception within one year of having regular intercourse with adequate frequency (4-5times a week)

·        Another 10 percent will achieve the objective by the end of second year.

·        About 10 percent remain infertile by the end of the third year.

Causes

          Conceptions depend 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 10 to 15 percent.

Male factors that cause infertility

 

1.     Defective spermatogenesis

         Spermatogenesis and sperm maturation need a high androgenic environment.  Spermatogenesis is predominantly controlled by the genes on the “y” chromosome.  The process of spermatogenesis take takes approximately 74 days for completion.  Additional 12 to 24 days are needed for spermatozoa to travel the epididymis. The causes of defective spermatogenesis are

Congenital.

Undescended testes is a congenital condition .

·        Hypospadias causes failure to deposit sperm in the vegina.

·        Thermal factor.

              The scrotal temperature has to be 1⁰to2⁰ less than the body temperature.

·        Loss of sperm motility .

·        Genetic.

Common chromosomal abnormality in azoospermic male is kleinfelters syndrome.

·        Iatrogenic.

              Radiation, cytotoxic drugs, blockers, antihypertensive, anticonvulsants drugs likely to hinder spermatogenesis.      

·        Immunological factor.

Antibodies against spermatozoa surface antigens may cause infertility.

·        Endocrine factor.

FSH level is seen raised in idiopathic testicular failure.

 

2. obstruction of the efferent ducts.

          The efferent ducts may be obstructed by gonococcal or tubercular infections.  Surgical trauma during vasectomy on herniorrhaphy may lead to obstructions.     

3. FAILURE to deposit sperm high in the vegina

·        Erectile dysfunction.

·        Hypospadias.

·        Absence of ejaculation.

4.Errors in seminal fluid

·        Usually high or low volume of ejaculate(normal volume is 2ml or more)

·        Low fructose content.

·        High prostaglandin content.

·        Undue viscosity.

 

5.Chronic alcoholism and cigarette smoking.

 

Female factors that cause infertility

1.     Ovarian factors.

·        An ovulation or oligo-ovulation

          Ovarian activity depends on gonadotropins which are related to the release GNRH from hypothalamus disturbance of these may result in an ovulation.

Tubal and peritoneal factors

          Tubal and peritoneal factors are responsible for about 30 to 40 percent of female infertility.  These include.

·        Peritubal adhesions.

·        Previous Tubal surgery.

·        Tubal spasm.

·        Salpingitis.

Uterine factors.

          These include factors that interfere with reception and nidation of fertilized ovum unfavorable endometrium.

Cervical factors

          Ineffective sperm penetration due to the following factors.

-         ­Chronic cervicities.

-           Presence of antisperms antibodies.

-         Second degree uterine prolapse.

-         Scanty vaginal mucus.

-         Congenital elongation of cervix.

 VAGINAL FACTORS.

-         Atresia.

-         Septum.

-         Narrow introitus.

 

Combined factors

          these include presence of factors both in female and male cause’s infertility.

·        Age of wife beyond 35 years and advancing age in men.

·        Infrequent intercourse (less than 4-5 in week) during fertile period (around ovulation).

·        Anxiety and apprehension.

·        Immunological factors (antisperms antibodies).

Investigation of female

HISTORY

·        History: age duration of marriage history of previous marriage with proven infertility if any.

·        Medical history: Tuberculoses pelvic inflammatory disease diabetes.

·        Surgical history: abdominal or pelvic surgery that can cause Peritubal adhesions.

·        Menustral history:  Hypo menorrhea or oligomenorrhea.

Previous obstetric history.

·        Contraceptive practices: Use of IUCD that have chance to produce PID.

·        Sexual problems:  Dyspariunia and loss of libido.

 

Examination

General examination.

          Obesity or marked reduction in weight abnormal distribution of hair and under development  of secondary sex characteristics.

Systemic Examination

          Hypertension organic heart disease etc.

Gynecologic Examination

          To look for vaginal infection, uterine size, shape, position and mobility.

Speculum Examination

          For presence of cervical discharge which if present needs to be tested for infection.

Diagnostic Evaluation

Menstrual history

Look for evidences of ovulation such as

Ø     Regular, normal menstrual loss between the ages of 20 to 35.

Ø     Midmenstrual bleeding or pain or excessive mucoid vaginal discharge.

Ø     Features of primary dysmenorrheal

Sonography

          Serial sonography during mid cycle can precisely measure the graffian follicle just prior to ovulation.

·        Laproscopy

·        Insufflation test – it is done to see the patency of fallopian tubes.

·        Semen analysis

·        Postcoital test

·        Basal temperature recording

·        Serum progesterone test and endometrial biopsy

·        Hysterosalpingogram

Management of Infertility

          Management of infertility would depend upon the cause identified, duration and age of the couple especially the female.

General Instructions

·        Body weight: Over weight or under weight.

·        Excess use of smoking and alcohol should be avoided

·        Ideal coital frequency: Intercourse or multiple during the fertile window period.

·        Avoidance of lubricants.

·        The use of fertility imparing medications should be avoided by both partners.

·        Psychological support should be offered as the couple may face significant stress and sadness as the investigations and consultation progress.

Management of male infertility

General Care

·        Improvement of general health

o       Reduction of weight in obese

o       Avoidance of alcohol and heavy smoking

o       Avoidance of tight and warm under garments

·        Avoiding medications that interfere with spermatogenesis.

·        Special treatments for causes identified such as

o       Intrauterine insemination (IUI)

It involves placing increased concentration of motile sperms close to the fallopian tubes by passing the endocervical canal which is abnormal

In vitro fertilization (IVF)

          Fertilization of an ovum outside the body is a technique used when a woman has blocked fallopian tubes or some other impediment to the union of sperm and ovum in the reproductive tract.  The woman is given hormone therapy causing a number of ova to mature at the same time several of them are then removed from the ovary through a laproscope.

Intracytoplasmic sperm injection (ICSI)

          This method is beneficial in the case of male factor infertility where the sperm counts are very low or failed fertilization with previous IVF attempts.

Artificial insemination with donor sperm (AID).

          When the semen of a donor is used for insemination, it is called artificial insemination donor

Surgical treatment

·        Correction of hydrocule

·        Vasbepididymostomy

Management of Female infertility

Ovary dysfunction

·        Induction of ovulation using drug such as citrate letrozole etc.

·        Correction of biochemical abnormality.

·        Substitution therapy – Thyroxin for hypothyroidism antidiabetic drugs for diabetes mellitus.

Surgery

·        Laproscopic ovarian drilling (LOD)

·        Surgical removal of functioning or adrenal tumor.

·        Cannulation and balloon tuboplasty for block in tube.

·        Salpingostomy to create an opening in tube in a completely occluded tube.

Nursing Management

·        Nurses meet couples seeking help for treatment of infertility in special centers or clinics where such services are available.

·        Assessing, educating, counseling to the couples about the infertility tests and procedures.

·        Provide psychological support to the couple who undergo infertility treatment.

·        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.

·        The nurse should take the detailed medical and family history from each partners.

·        During the period of therapy the couples need to avoid smoking, good diet, exercises, maintain health and take folic acid supplement if prescribed.

 

ROLE OF NURSE IN INFERTILITY CLINIC

          The role of nurse is continuously expanding and changing to meet the demands of couples undergoing infertility treatment.

1.     As a fertility nurse

Nurse have access to the information and the latest research in the field that is over changing.  They can provide informed medical timely support so that options and decisions are not overwhelmed.

2.     As a fertility coach

Nurse utilize their experience of coaching thousands of patients to bring the  right word, right judge, right question, the right challenge, nurse listen well and question effectively and draw out from clients the right decision regarding care.

3.     As a fertility consultant

They advance clients decision, making process by researching treatment plans,  explaining success statistics etc.

4.     As a fertility liaison

They can be client connection to clinic.  They will ask the important questions clients may not know to ask

5.     As a fertility advocate

They will stand for client in the event of problems and work on clients behalf to solve them successfully nurses will advocate clients wishes as they proceed with treatment and assure the best

6.     As a fertility confident

Nurses always know what is going on with client care it is often difficult to full share struggles, difficulties, nurse listens, understand, empathize in a way that encourages, energetize the client.

 

CONCLUSION

 

          The management of the infertility should be take place in the dedicated cline by trained staff.  There are two types of infertility primary infertility and secondary infertility.  In many cases 30% of couples get pregnant after simple history taking examination, invtigation and counseling without starting any treatment.  By the unnecessary treatment of husband and wife will harm or affect the future fertility.

BIBLIOGRAPHY

1.       A textbook of Standards of Practices for Integrated MCH / RH Services, 1^st Edition June 2005, Pg.No.385-392.

2.       A text book of Myles for Midwives, 14^th Edition.

3.       Howkins and Bourne Shaw’s Textbook of Gynaecology, 14^th Edition Elesiver Publications, Pg.No.180-192.

4.       A comprehensive text book for midwifery and Gynaecological Nursing, Annamma Jacob, Pg.No.716-724.