INFERTILITY

 

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

Comments

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