RNSG 1412 - Infertility/ Contraception
The Nurses' teaching for potentially increasing fertility would include which of the following initially? a. Reduce frequency of intercourse to less than once a week b. Clarify the validity of the degree of sexual satisfaction c. Instruct them to eliminate any additional lubrication
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What legal implications apply to advances in reproductive techniques?
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What is the main teaching for the male undergoing a vasectomy?
*** Some sperm will remain in the sperm ducts, male must have ejaculations to rid ducts of sperm. When he has 2 negative sperm counts, he then can resume sexual activity without use of another contraceptive. This can take up to 3 mnths The vas deferens are cut and ligated. The ends may be buried in the scrotal fascia. Sperm can no longer get from testes to penis. Semen no longer contains sperm. -Has no effect on potency -Male hormones are still produced, so male secondary sex characteristics are not affected -Sperm production continues but no transfer into the semen after successful vasectomy Patient Teaching: Apply ice to scrotum. Moderate activity for two days. Wear scrotal support for 2 days
Describe Microsurgical Assisted Fertilization.
-A small slit made into zona pellucida cells that surround the ovum to allow sperm to gain access. -Intracytoplasmic sperm injection-sperm injected directly into the egg.
What legal implications apply to the teenager seeking contraception? How may this differ from the nurse's ethical beliefs, what ethical principals allow the nurse to assist the teen in meeting her needs?
-Be sensitive to their feelings, concerns and needs -Be accepting of teenager regardless of personal feelings -Use understandable language when teaching -Reassure visits to dr are confidential -Teach about anatomy -Encourage them to talk to parents -
What are the least reliable methods of contraception?
-Breastfeeding -Coitus interruptus (removal of penis from vag before ejaculation)
Why is breastfeeding sometimes thought to be a form of contraceptive?
-Breastfeeding inhibits ovulation b/c suckling and prolactin interfere with secretion of Gonadotropin-releasing hormone and LH -Women who breast feed completly may avoid ovulation and resumption of menses -Women who bottle and breast feed can possibly ovulate
What are 2 additional forms of female mechanical barriers?
-Cervical Cap: Similar to the diaphragm but smaller, may stay in for up to 48 hours -Lea's Shield: Silicone sheet applied over cervix
What points should be discussed with the couple prior to sterilization?
-It is a permanent end to fertility -Reversal surgery is expensive -Not always successful -Not always covered by insurance
Why is gamete intrafallopian transfer (GIFT) more successful than IVF?
-Ovulation is induced similar to IVF -The ova are retrieved and they are placed directly into the fallopian tube along with the male's sperm. -This allows for fertilization to take place in the fallopian tubes -Success rates are higher -More acceptable since fertilization doesn't occur outside the body
What is the important teaching related to Depo Provera?
-Progestin injection that inhibits ovulation, alters endometrium. -Effective for 3 mnth-teach importance of re-injections -Can be used during breastfeeding and increases milk prod SE: breast tenderness, weight gain, HA, depression, decreased bone density **major reason for discontinuation = menstrual irregularities ** Nursing Implications: -Do NOT massage site after injection. It can accelerate absorption, and shorten period of effectiveness. -Increases risk for osteoporosis-teach about Ca, vit D intake and weight-bearing exercise
What is important teaching relating to the Transdermal contraceptive patch?
-Synthetic hormones (estrogen and progestin) are delivered directly through the skin and into the bloodstream via a patch. -Can wear the patch on the butt, abd, upper torso (front and back, excluding the breasts), or upper outer arm. -Replace on the same day of the week for 3 consecutive weeks, and week 4 is "patch-free." -Patch remains attached and effective while exercising, bathing or in hot, humid conditions. -Can cause skin irritation -No STD protection -Less effective if 198lbs or more
How is cervical mucus used in predicting ovulation and periods to avoid intercourse?
-There is no mucus 3-4 days after menses. Then thick, sticky mucus appears. -As estrogen increases the mucus changes to clear, slippery, and stretchy like egg white. -After ovulation, mucus decreases in amount and becomes thick and sticky again. -To prevent preg, avoid sex from the time mucus is first present after menses, until 4 days after the end of slippery mucus
What specific history findings indicate contraindications to use of oral contraception?
-Thrombophlebitis and thromboembolic disorders -Cerebrovascular or cardiovascular diseases -Estrogen-dependent cancer or breast cancer -Benign or malignant liver tumors -Hypertension -Migraines with focal aura -Diabetes with vascular involvement -Impaired liver function -Suspected or known pregnancy -Undiagnosed vaginal bleeding -Heavy cigarette smoking -Major surgery requiring prolonged immobilization
What information is important to teach the client who is having a sperm analysis? What is the most significant finding in male infertility?
1) He should collect the specimen by masturbation after a 3-day abstinence. 2) Teach him to note the time the specimen was obtained so the lab can evaluate liquefaction of the semen. To maintain warmth the specimen must be transported near the body and arrive at the lab WITHIN 1 hour.
What patient information is gathered during preconception counseling and a complete history and physical of each member of the couple?
1) Medical hx: age of menarche & characteristics, contraceptive methods (past/present), pregnancies/ complications/outcomes, prior surgeries, pattern of intercourse, length of time having sex w/o contraception, exposure to possible toxins, OTC tests used (ovulation predictor kits) 2) Physical exam 3) Diagnostic tests: BBT, evaluation of cervical mucous, hormone evals (estrogen, progesterone, LH, FSH, thyroid), u/s imaging, xray imaging, semen analysis, testicular biopsy
What is the difference between the 3 main types of birth control pills.
1) Single hormone = Progestin only 2) Combined hormone (COC) = progestin & estrogen 3) Extended-cycle COC = a 91 day regimen in which the woman takes a pill for 84 days followed by 7 days of menses. -Blanks=lactose pills or ferrous sulfate are taken for the last week so the patient remembers to take a pill everyday. ***Pill should be taken the same time each day**
What is the mechanism of action with chemical barrier contraception?
Act as spermicides
Why is infertility a psychological and economic strain on a couple?
Advanced Reproductive Techniques can cause much controversy and criticism. -Cost several thousand dollars and the chances of success are minimal, 10% -Must deal with chance of Multifetal pregnancies and / or Selective Reduction -Major psychological and economic strain on the couple -Influenced by the couples cultural, psychosocial background.
Describe semen analysis in relation to: Sperm amount, Sperm mobility & Seminal fluid
Assess for: -Number, appearance, motility -Amount--average ejaculation is 5cc. w/ a min of 20 million sperm/ml. of fluid (Normal 50 - 200 million/ml. of fluid) -Semen pH 7.2-7.8 -Liquefaction-usually occurs in 60 min.
During assessment, the nurse discovers that the patient's medical history includes a ruptured appendix and resulting peritonitis several years ago.Why might this data be pertinent to the patient's infertility problem? a.) the infection may have caused sterility b.) resulting scarring and adhesions may have caused tubal blocking c.) the appendix plays an important role in tubal functioning
B???
What is the purpose of a testicular biopsy and sperm penetration assay?
Biopsy = an invasive test for obtaining testicular tissue to identify pathology and obstructions sperm penetration assay = evaluates fertilizing ability of sperm; assesses ability of sperm to undergo changes that allow penetration of a hamster ovum from which the zona pellucida has been removed.
How does the woman calculate her fertile days using the Calendar Method?
Book=Record length of 6 cycles. Subtract 18 days from the shortest cycle & 11 days form the longest cycle to determine fertile period. PP=Calculate the time at which ovulation is likely to occur based on the length of previous menstrual cycles.The woman must keep a diary of her menstrual cycles. Abstain on the fertile days.
What is the reason for capicitation?
Capacitation is the act of separating the sperm from the semen and diluting it. This process also removes many of the antibodies that interfere with sperm motility and ability to penetrate the ovum. Normally after intercourse, the cervical mucus removes the seminal fluid.
What are types of spermicides available and what teaching points must the nurse include when discussing with the woman/couple?
Creams or gels used with diaphragms, cervical caps and condoms -Do not protect against STD's -No rx needed -Can irritate skin -Place deep in the vagina so it comes in contact with the cervix before intercourse -Max effectiveness lasts about one hr. Must reapply. -Suppositories take 10-30 minutes to dissolve -Don't douche for six hours following use
What treatments are used for emergency contraception? What patient teaching is important for each?
Ella (ulipristal acetate): Rx only-estrogen and progestin. Acts to delay/block luteinizing surge & ovulation-may also inhibit implantation. Can be used up to 5 days after sex. Plan B: progestin-only method=OTC to women 17 + yrs old. Only effective if ovulation has not occurred. Most effective if used w/i 72 hrs after sex. Copper IUD: inserted w/i 5 days of sex & is up to 99% effective
What is the important teaching related to NuvaRing vaginal contraceptive ring?
Estrogen and progestin release is activated once ring comes into contact with the vagina. -The hormones are absorbed into the bloodstream. -In a given 1-mnth period, must be inserted into the vagina, removed after 3 wks, and a new ring must be inserted no >7 days later.
Define infertility.
Inability of a couple to conceive after 1 yr of regular intercorse (2-3x wkly) w/o using contraception; also the involuntary inability to conceive and produce viable offspring when the couple chooses. Primary infert-couple who have never conceived. 2ndary-couple who have conceived at least once before. PP says "inability to achieve conception after one year of unprotected intercourse"
What information does the nurse include when teaching the client about the administration and side effects of menopausal gonadotropins (Pergonal ®) ?
Induction of ovulation with human-derived FSH & LH
How is Basal Body Temperature (BBT) used to determine fertility or improve potential for fertilization? What should be taught to the patient?
Keep a chart of oral temperatures taken at the same time every day with a BASAL thermometer. Teach the woman to assess for the drop and then rise in her temperature as ovulation occurs. Look for the check-mark on the graph. **Monitor BBT for 3 - 4 months to be effective.** Teach about factors that may alter temperature: infection, fatigue, less than 3 hours of sleep, awakening late, sleeping in a heated waterbed or under a heating blanket, jet lag.
What is the difference between laparoscopy and hysteroscopy? How is each used to assist with infertility treatment?
LAP = General anesthesia, incision is made in the umbilical area. Peritoneal cavity is distended with CO2 gas. Pelvic organs are visualized with a fiber optic instrument. Dye can be injected into the uterus and tubes to check patency. Pelvis can be evaluated for adhesions, cysts, tumors, and endometriosis. HYST = Visual inspection of the uterus through the insertion of a scope through the cervix. Usually follows a hystersalpingography
What are factors in the male that contribute to infertility? What are factors in the female that contribute to infertility?
Male- -Abnormalities of sperm (oligospermia-low #. 20 mill is low, 35-200 mill avg) -Abnormal erections -Abnorm ejaculations (retrograde ejac=discharge of semen in bladder, or ED) -Abnormal seminal fluid. Women: 1) FAVORABLE CERVICAL MUCUS - mucus that is not too acidic, kill off sperm. Must also be thin, watery, stretchable to allow the sperm to get through. 2) CLEAR PASSAGE BETWEEN CERVIX AND TUBES - no abnormal strictures in the tubes 3) PATENT TUBES WITH NORMAL MOTILITY - fallopian tubes have peristalsis and movable cilia that assist the fertilized ovum to move from the distal end to the proximal end . 4) Ovulation and Release of Normal Ova - the woman must release an egg each month. 5) Endometrium prepares for implantation -- endometrium must get thick and have nutrients ready to support the fertilized ovum. -Must have normal shaped uterus
Explain the process of therapeutic insemination including indications for use, process, and psychosocial implications.
May use either the Husband's Semen (THI) or that of a donor (TDI). The conception rate is = 30% with donor's semen & 15% with husband's semen (lower because lack of sperm or something wrong with the husband's sperm). Sperm is "washed" and placed directly in the uterus with a small catheter. The woman is to remain in supine position with hips elevated for about 20 - 30 minutes REMEMBER = Fresh sperm cannot fertilize an ovum, it must be capacitated "washed" first. Capacitation is the act of separating the sperm from the semen and diluting it. This process also removes many of the antibodies that interfere with sperm motility and ability to penetrate the ovum.Normally after intercourse, the cervical mucus removes the seminal fluid.
Describe the procedure for HYSTEROSALPINGOGRAPHY and its purpose.
Primarily used to examine women who have difficulty becoming pregnant allowing the radiologist to evaluate: -shape and structure of the uterus -openness of the fallopian tubes -peritoneal cavity for any scarring, adhesions Procedure: Instill a radiopaque dye into the uterine cavity under pressure. The substance fills the uterus, tubes, and spills into the peritoneal cavity. Viewed with x-ray Purpose = Reveals tubal patency and any distortions of the uterus / endometrial cavity. Can be therapeutic by flushing debris, breaking adhesions, and just clearing the tubes. Can cause uterine cramping and referred shoulder pain.
Describe the Post Coital Exam-HUHNER and its purpose.
Purpose: Test the ability of the sperm to survive the cervical barrier and its secretions Procedure: - Assess time of ovulation and have intercourse - Go to health facility within 2 - 8 hours after sex -Semen and cervical mucus are retrieved by aspiration with a catheter and then tested. Test for: Quality of cervical mucus, sperm penetration through the mucus, number of active sperm,and signs of infection.
What information does the nurse include when teaching the client about the administration and side effects of Clomid ® (clominphine citrate)?
S/E =Anti-estrogenic may cause: - a DECREASE in cervical mucus production -Hot flashes -Abdominal Bloating -Breast Tenderness -Nausea and Vomiting -Ovarian enlargement -Visual Disturbances Action: stimulates follicular growth by increasing secretion of FSH and LH Patient Teaching: Take the drug for 5 days starting day 5-9 of menstrual cycle. Usually start with 50 mg. and increase to 250 mg. **Success- 40% become pregnant**
What factors must the couple consider when choosing a contraceptive?
Safety Protection from sexually transmissible diseases Effectiveness Acceptability Convenience Education needed Side Effects Benefits Interference with spontaneity Availability Expense Preference Religious and personal beliefs Culture
What is the difference between Tubal Embryo Transfer (TET) & Zygote Intrafallopian Transfer (ZIT) ?
TET = Fertilization occurs outside body ZIT = zygote placed in the fallopian tubes so can enter the uterus naturally for implantation
Describe Cervical Mucus Testing and how to evaluate spinnbarkheit.
Teach the appearance of the cervical mucus at various stages of the menstrual cycle. At time of ovulation becomes thin, watery, clear. EVAL Spinnbarkheit: Teach the woman to assess for egg-white consistency and stretchability of the mucus. Put mucus between two fingers and pull apart and assess stretchability. At time of ovulation, mucus should stretch 6 cm (2.3 inch) or more.
What hormones must the male have in order to produce viable sperm?
Testosterone, LH, FSH
Describe the procedure for an Endometrial biopsy and its purpose.
This test is performed after ovulation during the luteal phase of the menstrual cycle about 2 - 4 days before the expected menses. A sample of the endometrium is removed and sent to the lab for study. Purpose = Assess the corpus luteum and the receptivity of the endometrium for implantation. (Did it make a good home?) Responding from estrogen and progesterone stimulation.
What are methods used for tubal sterilization?
Tubal ligation = surgical procedure where fallopian tube is ligated- sperm and ovum can no longer meet. Prevent passage of sperm or egg in the fallopian tubes by: clips or blocking, cautery, remove part of tube. May be done immediately following delivery or at a later date. Side effects: Infection, Hemorrhage, Perforation of intestines, Reversal is only 15% success rate Tubal sterilization = nonsurgical. Insertion of small coil (Essure) into the fallopian tubes or Silicone implant (Adiana) into the fallopian tubes. Tubes become blocked as tissue grows.
Describe the procedure for a Laparoscopy and its purpose.
Under general anesthesia, entry made through an incision in the umbilical area. Peritoneal cavity is distended with carbon dioxide gas. Pelvic organs are visualized with a fiber optic instrument. Dye can be injected into the uterus and up the tubes to check patency. Purpose = The pelvis can be evaluated for adhesions, cysts, tumors, and endometriosis
When is in vitro fertilization utilized? (who is a candidate for IVF?)
Used for: 1) women who have blocked or damaged fallopian tubes, 2) male sperm count low, 3) Infertility is long term and unexplained PROCEDURE: 1. Ovulation is induced using fertility drug( Lupron, Follistim, Gonal F, Clomid) Ovarian function is monitored. 2. Ripened, mature ova are aspirated from the ovaries during laparoscopy or transvaginally. 3. The ova are incubated for at least 8 hours then transferred to culture media 4. Sperm that have been capacitated are added to the ova in a perti dish 5. After fertilization, zygotes are allowed to grow and then transferred to the uterus through a catheter. 6. The woman may be given Progesterone injections to enhance receptivity of the endometrium to implantation.
What would the nurse tell the couple about the purpose and findings of the following tests? a) Hormonal testing b) Endometrial biopsy c) Transvaginal ultrasound
a) Gonadotropins (FSH and LH) = assess LH surge that should occur immediately before ovulation. Used for ovulation prediction. Progesterone assays = measured toward the end of the cycle to assess if the levels remain high. Tells more about the ovulation and corpus luteum functioning. b) Endometrial Biopsy - usually done toward the end of the cycle to assess secretory function and if the endometrium has nutrients and is thickened. c) Transvaginal Ultrasound - best used for follicular monitoring.
What are benefits and disadvantages of each mechanical barrier and patient teaching? a) Intrauterine Device (IUD) b) Condom (male & female) c) Vaginal sponge d) Diaphragm
a) Mirena Intrauterine System, releases *progestin*, may be left in place for up to 5 yrs. Causes a sterile inflammatory response creating a spermicidal environment. Patient must check the "string" placement after menses and before intercourse. Side Effects= PID, increase in bleeding and spotting, cramping, uterine perforation. Report pelvic pain. b) MALE: sheath to cover the penis FEMALE: sheath inserted into the vagina and anchored around the cervix -Prevent the transport of sperm to the ovum -Some should be used with a spermicide -Teach how to apply and how to remove to be effective. c) Moisten well with water and insert into the vagina with the concave portion positioned over the cervix. Should be left in place for 6 hours and may be worn for 24 hours. d) Dome shaped rubber device with a flexible wire rim that covers the cervix-fitted by the HCP. May be used with gel or foam. Should not be removed for 6 hrs after the last intercourse. Can stay in place up to 48 hrs.
What is patient teaching related to the insertion of a diaphragm?
a.) Apply jelly to the rim and center of the diaphragm. b.) insert the diaphragm, pushing the rim of the diaphragm under the symphysis pubis. c.) Check placement of the diaphragm. Cervix should be felt through the diaphragm. **Main teaching=Be sure to be re-evaluated for fit following delivery, pelvic surgery, or a weight gain or loss of 10 pounds.