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
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