Ch. 5 Maternity: Infertility, contraception and abortion

Second trimester abortion

-Dilation and evacuation -Cervical preparation with prostaglandins -Emotional considerations

Assessment of female infertility -Test or examination

-Evaluation of the anatomy -Detection of ovulation -Hormone analysis -Ultrasonography: evaluate follicular development -Endometrial biopsy -Hysterosalpingography: evaluate tubal patency -Laparoscopy: if suspicious of endometriosis, tubal damage, adhesions

Calculating Ovulation

-Follicular phase is variable length while the luteal phase is 14 days in length -Count back 14 days from 1st day of menses to get day of ovulation -Fertile window: Range for different lengths of menstrual cycles Ex. -Menstrual Cycle #1=30 days-14=Day 16 -Menstrual Cycle #2=32 days-14=Day 18 -Menstrual Cycle #3=28 days-14=Day 14 -Fertile Window: Day 14-18 (when pt ovulates)

Assessment of male infertility

-Hormonal factors -Testicular factors: trauma -Factors associated with sperm transport and other sperm factors: low sperm count, abnormal shape/function, hypospadias, retrograde ejaculation, varicocele, dysfunctional sperm/can't fertilize -Idiopathic male infertility -Previous infections -Semen analysis: sperm count, morphology, motility and evidence of infection -Hormone analysis -Scrotal ultrasound -Hamster egg penetration test!?!!?

Assisted reproductive therapies

-In vitro fertilization-embryo transfer (IVF-ET) -Gamete intrafallopian transfer (GIFT) -Zygote intrafallopian transfer (ZIFT) -Ovum transfer (oocyte donation) -Therapeutic donor insemination (TDI) -Embryo hosting -Assisted embryo hatching

Common complications of abortion

-Infection -Retained products of conception -Excessive vaginal bleeding

Contraception

-Intentional prevention of pregnancy -Birth control is the device or practice to decrease the risk of conceiving -Family planning is the conscious decision on when to conceive or avoid pregnancy -May still be at risk for pregnancy -Nearly half of all U.S. pregnancies are unplanned

Combined estrogen-progestin contraceptives (COCs) -types -how do they work?

-Oral contraceptives: 24 hours -Transdermal contraceptive system: 7 days -Vaginal ring: 3 weeks -How does it work? -->Prevents ovulation, thickens cervical mucus, thin endometrium lining.

Progestin-only contraceptives -types -how do they work? -s/e

-Oral progestins (minipill) -Injectable progestins (DMPA or Depo-Provera)- keep in mind ability to get pregnant afterwards and decreased BMD -Implantable progestins (Norplant, Nexplanon, Implanon) -More about thickening cervical mucus; may prevent ovulation as well Side effects for progestins: irregular menstrual bleeding, HA, nervousness, nausea, skin changes, vertigo

Abortion

-Purposeful interruption of pregnancy before 20 weeks of gestation -->Elective -->Therapeutic Nurse role: Right to choose, inform employer Legal and moral issues Roe v. Wade 1973

Fertility awareness methods (FAMs)

-Rely on avoidance of intercourse during fertile periods -FAMs combine charting menstrual cycle with abstinence or other contraceptive methods -Natural family planning (period abstinence) -Calendar rhythm method -Standard days method -Basal body temperature method -Cervical mucus ovulation-detection method -Symptothermal method: BBT + Cervical mucus Predictor test kits for ovulation: LH surge -TwoDay method: "Did I note secretions today or yesterday?" -Breast-feeding: LAM, prolactin inhibits estrogen; infant < 6 months of age, exclusive, feeds approx q4hrs

IUD

-Small, T-shaped device wrapped in copper inserted into the uterine cavity (Paraguard)-works by preventing fertilization, spermicide, inflames endometrium -Medicated intrauterine system loaded with progestational agent (Mirena)-same as other progestin agents -IUD offers no protection against STIs or HIV

First trimester abortion

-Surgical (aspiration) abortion -Medical abortion -->Methotrexate and misoprostol -->Mifepristone and misoprostol *Induced abortion performed in the first trimester is safest and less complex

Reproductive alternatives

-Surrogacy -Preimplantation genetic diagnosis -Adoption -Cryopreservation of human embryos

Emergency contraception

-Used within 72 hours of unprotected intercourse; may be ineffective if overweight, obese -No effect if already pregnant -Prevents ovulation by inhibiting follicular development -Five methods available in the United States -->High doses of estrogen or COCs (Ella, Plan B One-Step, COC) -->Two days of levonorgestrel (Next Choice) -->Insertion of the copper intrauterine device (IUD) -within 8 days

Barrier methods

1) Spermicides: decreases mobility 2) Condoms, male (STI protection) Vaginal sheath (STI protection) 3) Diaphragm 4) Cervical cap 5) Contraceptive sponge

A physician prescribes clomiphene citrate (Clomid, Serophene) for a woman experiencing infertility. She is very concerned about the risk of multiple births. The nurse's most appropriate response is: A. "This is a legitimate concern. Would you like to discuss this further before your treatment begins?" B. "No one has ever had more than triplets with Clomid." C. "Ovulation will be monitored with ultrasound so this will not happen." D. "Ten percent is a very low risk, so you don't need to worry too much."

A

The nurse must evaluate a male patient's knowledge regarding the use of a condom. The nurse would recognize the need for further instruction if the patient states that he: A. lubricates the condom with a spermicide containing nonoxynol-9. B. leaves an empty space at the tip of the condom. C. leaves a small amount of air in the tip. D. removes his still-erect penis from the vagina while holding onto the base of the condom.

A Nonoxynol-9 is no longer recommended. Recent data suggest that frequent use of nonoxynol-9 may increase human immunodeficiency virus transmission and can cause genital lesions. An empty space at the tip of the condom is the correct instruction. Leaving a small amount of air at the tip of the condom is the correct instruction. Removing the condom while holding the base is the correct instruction.

Infertility

Affects about 10% to 15% of reproductive-age couples Def: If less than age 35, unsuccessfully trying to conceive for 1 yr (if greater than age 35, it's 6 months)

Factors Associated with Infertility

Assessment of female infertility: -Ovarian factors-anovulatory cycles -Tubal and peritoneal factors-PID, ectopic, endometriosis -Uterine factors-bifurcation -Vaginal-cervical factors: stenosis, inadequate mucus, incompetent cervix -Other factors (chromosomal, endocrine)

A woman inquires about herbal alternative methods for improving fertility. Which statement by the nurse is the most appropriate when instructing the woman in which herbal preparations to avoid while trying to conceive? A. "You should avoid nettle leaf, dong quai, and vitamin E while you are trying to get pregnant." B. "You may want to avoid licorice root, lavender, fennel, sage, and thyme while you are trying to conceive." C. "You should not take anything with vitamin E, calcium, or magnesium. They will make you infertile." D. "Herbs have no bearing on fertility."

B Rationale: Nettle leaf, dong quai, and vitamin E promote fertility. Herbs that a woman should avoid while trying to conceive include licorice root, yarrow, wormwood, ephedra, fennel, goldenseal, lavender, juniper, flaxseed, pennyroyal, passionflower, wild cherry, cascara, sage, thyme, and periwinkle. Vitamin E, calcium, and magnesium may promote fertility and conception. Although most herbal remedies have not been proven clinically to promote fertility, women should avoid the following herbs while trying to conceive: licorice root, yarrow, wormwood, ephedra, fennel, goldenseal, lavender, juniper, flaxseed, pennyroyal, passionflower, wild cherry, cascara, sage, thyme, and periwinkle.

A male client asks the nurse why it is better to purchase condoms that are not lubricated with nonoxynol-9 (a common spermicide). The nurse's most appropriate response is: A. "The lubricant prevents vaginal irritation." B. "Nonoxynol-9 does not provide protection against sexually transmitted infections, as originally thought; also it has been linked to an increase in the transmission of human immunodeficiency virus (HIV) and can cause genital lesions." C. "The additional lubrication improves sex." D. "Nonoxynol-9 improves penile sensitivity."

B Rationale: Nonoxynol-9 may cause vaginal irritation. This is a true statement. Nonoxynol-9 has no effect on the quality of sexual activity. Nonoxynol-9 has no effect on penile sensitivity.

Semen analysis is a common diagnostic procedure related to infertility. In instructing a male patient regarding this test, the nurse would tell him to: A. ejaculate into a sterile container. B. obtain the specimen after a period of abstinence from ejaculation of 2 to 5 days. C. transport specimen with container packed in ice. D. ensure that the specimen arrives at the laboratory within 30 minutes of ejaculation.

B Rationale: The male must ejaculate into a clean container or a plastic sheath that does not contain a spermicide. An ejaculated sample should be obtained after a period of abstinence to get the best results. He should avoid exposing the specimen to extremes of temperature, either heat or cold. The specimen should be taken to the laboratory within 2 hours of ejaculation.

An infertile woman is about to begin pharmacologic treatment. As part of the regimen, she will take purified follicle-stimulating hormone (FSH) (urofollitropin [Metrodin]). The nurse instructs her that this medication is administered in the form of a/an: A. intranasal spray. B. vaginal suppository. C. intramuscular injection. D. tablet.

C Rationale: Intranasal spray is not the appropriate route for urofollitropin. Vaginal suppository is not the correct route for urofollitropin. Urofollitropin is given by IM injection; the dosage may vary. Urofollitropin cannot be given by tablet; it is given only by IM injection.

A woman is using the basal body temperature (BBT) method of contraception. She calls the clinic and tells the nurse, "My period is due in a few days, and my temperature has not gone up." The nurse's most appropriate response is: A. "This probably means you're pregnant." B. "Don't worry; it's probably nothing." C. "Have you been sick this month?" D. "You probably didn't ovulate during this cycle."

D Rationale: Pregnancy cannot occur without ovulation (which is being measured using the BBT method). A comment such as this discredits the client's concerns. Illness would most likely cause an increase in BBT. The absence of a temperature decrease most likely is the result of lack of ovulation.

Discharge instructions after tubal ligation should include: (Select all that apply.) A. being prepared for significant mood swings due to hormonal influences. B. expecting heavier menstrual periods. C. using two forms of birth control to prevent pregnancy. D. not expecting change in sexual functioning; may enjoy more. E. using condoms to prevent sexually transmitted infections.

D, E Rationale: Patient teaching regarding what to expect after tubal ligation includes: • You should expect no change in hormones and their influence. • Your menstrual period will be about the same as before the sterilization. • You may feel pain at ovulation. • The ovum disintegrates within the abdominal cavity. • It is highly unlikely that you will become pregnant. • You should not have a change in sexual functioning; you may enjoy sexual relations more because you will not be concerned about becoming pregnant. • Sterilization offers no protection against sexually transmitted infections. Therefore you may need to use condoms.

Sterilization of female vs female

Female -->Tubal occlusion -->Tubal reconstruction Male (vasectomy) -->Tubal reconstruction (reanastomosis)

Medical therapy and surgical therapies for infertility

Medical therapy -Clomiphene citrate: anti-estrogen to increase pulse frequency of FSH and LH (increase follicle development); may cause moodiness, hot flashes, multiple gestations, thickened cervical mucus, limited endometrial development -Letrozole: aromatse inhibitor, suppress estrogen in follicular phase Surgical therapies Assisted reproductive therapies (ART)

Test for ovulatory function

Progesterone levels (midluteal); > 3 ng/mL=ovulation LH surge: OTC urinary ovulation predictor kits FSH and estradiol testing: day 3 and 10 FSH levels (should be low and same) and day 3 estradiol level (low also) BBT: 1 degree increase 1-2 days after surge

A married woman has made the decision to use a diaphragm as her primary method of birth control. The clinic nurse should provide which instructions regarding care of, insertion, and removal of the diaphragm? (Select all that apply.) A. Remove the diaphragm by catching the rim from below the dome. B. Avoid using mineral oil body products. C. On insertion, direct the diaphragm down toward the space below cervix. D. Wash diaphragm monthly with mild soap and water. E. A dusting of cornstarch is appropriate after drying the diaphragm.

b, c, d, e Rationale: The diaphragm should not be removed by trying to catch the rim from below the dome. Oil-based products can cause the breakdown of the rubber. The diaphragm should be inserted into the vagina, directing it inward and downward as far as it will go to the space behind and below the cervix. The diaphragm should be washed after each use with mild soap and water. Cornstarch may be used. Avoid use of scented talc, body powder, and baby powder because they can weaken the rubber.

A 26-year- old woman is considering Depo-Provera as the form of contraception that is best for her since she does not like to worry about taking a pill every day. To assist this woman with decision making concerning this method of contraception, the nurse would tell her that Depo-Provera: A. is a combination of progesterone and estrogen. B. is a small adhesive hormonal birth control patch that is applied weekly. C. thickens and decreases cervical mucus, thereby inhibiting sperm penetration and ovulation. D. has an effectiveness rate in preventing pregnancy of 99% when used correctly.

c Rationale: Depo-Provera is a progestin-only form of hormonal contraception. Depo-Provera is administered as an intramuscular injection. In addition to the changes in the cervical mucus, some but not all ovulatory cycles are suppressed, and formation of an endometrium capable of supporting implantation is inhibited. The effectiveness rate is 99% or greater over 5 years.