Infertility

INFERTILITY :- 

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

Primary infertility denotes those patients who have never conceived. Secondary infertility indicates previous pregnancy but failure to conceive subsequently.

Fecundability is defined as the probability of achieving a pregnancy within one menstrual cycle. In a healthy young couple, it is 20 percent. Fecundity is the probability of achieving a livebirth within a single cycle. 

CAUSES OF INFERTILITY :-

 

1. Causes of female infertility :-

•  Ovarian dysfunction 
• Anovulation
• Oocyte maturation defect
• Tubal dysfunction 
• Altered tubal motility
• Pelvic adhesions, tubal obstruction
• Distortion of normal tube and ovarian relationship
• Impaired pick up of oocyte by the fimbria. 
• others

1. Dyspareunia
2. Abnormal peritoneal fluid 
3. Fertilization and implantation failure 
4. Early miscarriage

2. Causes of male infertility :- 

(i)Pre testicular 

• Endocrine
• Gonadotropin deficiency
• Obesity
• Thyroid dysfunction

(ii)Testicular 

• Cryptoorchidism :- a condition in which one or both of the testes fail to descend from the abdomen into the scrotum.
• Varicocele :- Enlargement of veins within scrotam
• Primary testicular failure

(iii) Post - testicular 

• Absence of vas deferens
• Tuberculosis, Gonorrhea
• Vasectomy

 3. Others :- 

• Ejaculatory failure
• Retrograde ejaculation

Diagnositic Evaluation :-

Both male and female partners should be evaluated points to be discussed with the couples. 

1.History taking

For female partner

• Age 
• Number of years married
• Contraception used 
• Sexual history
• Menstrual history
• Previous surgery
• Habits 

For male partners

• Occupation
• Smoking/alcohol/substance abuse 
• Sexual history
• Anosmia 
• Past history
• Injury

- Physical Examination

1.General examination

2. Breast examination

3. Sign of thyroid dysfunction

4. Abdominal examination - mass arising from the pelvis, Scars of surgery

5. Speculam examination 

INVESTIGATION :- 

For females :- 

1.Test for ovulation

 -  serum progesterone

- Ovulation index :- Urine distick test to determine whether the surge in LH that precedes follicular rupture has occured. 

- Transvaginal sonography

2. Test for tubal peritoneal factors

- Hysterosalpinography :- Hysterosalpingogram is an imaging procedure performed to assess the causes of infertility in females.

- Falloposcopy :- Falloposcopy (occasionally also falloscopy) is the inspection of the fallopian tubes through a micro- endoscope. 

- Laparoscopy

For males :- 

1.prostate massage and specimens of secretions for culture.

2.Post ejaculatory urine specimen to check retro grade ejaculation of sperm

3.Semen analysis

4.Doppler ultrasound 

5. MRI - that is for identifying anatomical abnormalities. 

Objectives :- 

1. To detect the etiological factor. 

2. To rectify the abnormality in an attempt to improve the fertility

3. To give assurance with explanation to the couple if no abnormality is detected. 

Management :- 

Treatment of ovulatory dysfunction :- 

Ovulation inducing agent 

Ex. Clomiphene citrate, Menotropins. 

Treatment of tubal occlusion

Proximal tubal occlusion

- Selective salpingograpgy

- Radiologically guided tubal cannulation 

- Hysteroscopic cannulation

Micro- surgery 

Distal tubal occlusion

- Fimbrioplasty

- Neosalpingostomy

- Salpingectomy and in vitro

Specific treatment for infertility

Assisted reproductive technology (ART)-is defined as the technology used to achieve pregnancy in procened as such as artificial insemination, in vitro fertilizatiodures, surrogacy.

 There are techniques that are:

1. Artificial insemination (AI)-introduction of sperm into the female's uterus or cervix for the purpose of achieving pregnancy through in vivo fertilization by means other than sexual intercourse. ART involves removing of eggs from a woman body and mixing with sperm in the laboratory.

II. Intrauterine insemination (IUI) is a procedure in which a catheter is inserted through the cervix into the uterus to deposit a sperm sample directly into the uterus.

III. In vitro fertilization (IVF) is a process by which an egg is fertilized by sperm outside the body.

IV. Zygote intrafallopian transfer (ZIFT) is an ART designed to transfer the fertilized embryo into the fallopian tube instead of the uterus. Zygote is place in the fallopian tube through which it will reach into the uterus. It is similar to IUF.

V. Intracytoplasmic sperm injection (ICSI) is the most successful form of treatment who are infertile. ICSI only requires one sperm which is injected directly into the egg and fertilized egg is transferred to uterus.

Management of man infertility 

1.For men :- if there is varicose vein in scrotum it can be removed surgically. 

2.Premature ejaculation and erectile dysfunction :- behavioural approach and medications 

3.Blockage of the ejaculatory duct :- sperm can be taken directly from the testicles and injected into an egg in laboratory. 

4.Retrograde ejaculation :- Sperm can be taken directly from the bladder and injected into an egg in laboratory. 

5.Surgery of epididimal blockage :- A bypass of the blockage can be performed called vasoepididymostomy ( vas deferens is re - connected to epididymis) 

INFERTILITY COUNCELLING :- 

Infertility counseling deals with the psychosocial impact of infertility related to intervention, treatment, and after-effects of both successful and unsuccessful treatments. It also involves therapeutic work to help patient cope with the consequences of infertility and treatment.

Benefit of infertility counselling :- 

1.Helps to deal with the emotional stress 

2.Provide extra support 

3.Allow the client in exploring all possible options for family 

4.Helps the couples in overcoming the dilemmas and deciding the right fertility treatment. 

5.Explain about the infertility management and specific treatment. 

Role of nurse in infertility counseling :- 

1. History collection about the patient, prenatal, family and other relevant history. 

2. Nurses has to perform primary physical examination  and collect other relevant information regarding patients of reports. 

3.Collect other information about tests, reports and documents. 

4.Establish plan of care with family and coordinate care with other healthcare professionals. 

5.Maintain good rapport , make them accesible and comfortable for counseling. 

6.Maintain privacy and confidentiality of all cases. 

7.Ensure follow up and supportive services to individual and family during counseling.