Chapter 7: Difficulty Conceiving a Child: Infertility

Chapter 7: Difficulty conceiving

To provide information about reasons for couple experiencing infertility and related nursing care

In primary subfertilittility, there have been

no previous conceptions;

IMPLEMENTATION

1.Fertility testing can be costly for a couple because not all health insurance programs provide reimbursement for these procedures. Because of this, be certain couples are informed beforehand of specific estimates of the cost of testing or therapy so they can budget and plan their resources and the next steps they want taken. 2.Suggesting a couple combine involvement with fertility testing with ongoing activities or beginning new activities together, such as taking a night school course, planting a garden, or learning a new sport or hobby, is a way of helping them reduce the feeling that their entire existence revolves around the testing procedures. 3.Throughout testing, couples need thorough education about the various procedures being done. Make sure to review any specific instructions about preprocedural and postprocedural care. 4.Couples need the active support of healthcare personnel from the first day they brace themselves to ask "Exactly why are we childless?" until the end, regardless of the results.

ANOVULATION What are required to prevent this ?

-Nutrition, body weight, and exercise are all important for adequate ova production because they all influence the blood glucose/insulin balance

Subfertility Subfertility is said to exist when a pregnancy has not occurred after at least

1 year of engaging in unprotected coitus

FERTILITY TESTING Basic fertility testing is geared toward answering three questions:

1. Is there sperm of good quality and number available? 2. Are ova (eggs) available (i.e., woman is ovulating)? 3. Is it possible for the sperm and egg to meet in a receptive environment? To answer these questions, only three tests are commonly used: -semen analysis in men and ovulation monitoring and tubal patency assessment in women

Semen Analysis On average, ejaculation for a semen analysis should produce a minimum of 1.4 to 1.7 ml of semen and should contain a minimum of 33 to 46 million spermatozoa per milliliter of fluid ( Semen analysis includes the following steps:

1. The patient is instructed to be sexually abstinent 2 to 4 days prior to the analysis. 2. The patient ejaculates by masturbation into a clean, dry specimen jar or a special condom (one without spermicide). 3. The number of sperm in the specimen are counted and then examined under a microscope within 1 hour of ejaculation - refrain from it chiling or warming up

For the procedure,

1.one or more mature oocytes are removed from a woman's ovary by laparoscopy and fertilized by exposure to sperm in a laboratory. 2.About 40 hours after fertilization, the laboratory-grown fertilized ova (now zygotes) are inserted into a woman's uterus, where, ideally, one or more of them will implant and grow.

If an endometrial biopsy is required, it is done

2 or 3 days before an expected menstrual flow (day 25 or 26 of a typical 28-day menstrual cycle). After a paracervical block and a screen for chlamydia, a thin probe and biopsy forceps are introduced through the cervix. Occurs: A woman may experience mild-to-moderate discomfort from maneuvering the instruments. There may be a moment of sharp pain as the biopsy specimen is taken from the anterior or posterior uterine wall. Possible complications include: pain, excessive bleeding, infection, and uterine perforation. This procedure is contraindicated if pregnancy is suspected (although the chance it would interfere with a pregnancy is probably less than 10%) or if an infection such as acute PID or cervicitis is present. Caution the woman that she might notice a small amount of vaginal spotting after the procedure. For follow-up, she needs to telephone her primary care provider if she develops a temperature greater than 101°F, has a large amount of bleeding, or passes clots. She needs to telephone the healthcare agency when she has her next menstrual flow because this helps "date" the endometrium and the accuracy of the analysis.

Therapy for Increasing Sperm Count and Motility If sperm are present but the total count is low, a man may be advised to abstain from coitus for

7 to 10 days at a time to increase the count. Ligation of a varicocele (if present) and changes in lifestyle, such as avoiding recreational marijuana use, wearing looser clothing, avoiding long periods of sitting, and avoiding prolonged hot baths, may also help reduce scrotal heat and increase the sperm count

It is possible for fallopian tubes, which have been ligated as a contraception procedure, to be reopened surgically but the success of the operation is not more than

70% to 80%. Also, the irregular incision line left by surgery can result in an ectopic pregnancy (i.e., a tubal pregnancy) if a fertilized ovum is stopped at the irregular point

Ovulation Determination by Test Strip

A woman dips a test strip into a midmorning urine specimen and then compares it with the kit instructions for a color change. Such kits are purchased over the counter, are easy to use, and have the advantage of marking the point just before ovulation occurs rather than just after ovulation, as is the case with BBT. They are not as economical as simple temperature recording, but they are advantageous for women with irregular work or daily activity, which can make BBT measurements inaccurate. -The woman's result is available in 30 minutes; the man's result is available in 10 minutes. The kits are expensive but can be helpful to a couple as a first step in self-fertility testing. Be certain the woman realizes this is not a test of her time of ovulation but a test whether she has adequate FSH to stimulate egg growth; therefore, she shouldn't use the test at the midpoint of her menstrual cycle.

ADOPTION

Adoption is an alternative for subfertile and LGBT couples, those individuals who have genetic-related health conditions or health conditions that would make pregnancy high risk. There are now fewer children available for adoption in the United States than there were in the past. Couples often consider physically or cognitively challenged children or children born outside the United States for adoption

ALTERNATIVE INSEMINATION

Alternative or IUI is the instillation of sperm from a masturbatory sample into the female reproductive tract by means of a cannula to aid conception at the time of ovulation The sperm can either be instilled into the cervix (intracervical insemination) or directly into the uterus (IUI) at the time of predicted ovulation. BBT charting, mucus analysis, or urinary test kits for LH can be used to detect the day of ovulation

A male is diagnosed as being infertile, but he wants to have children with his spouse. Which response should the nurse provide to this patient? A) "You need to consider donor-alternative insemination." B) "The chance of conception is slight with artificial insemination." C) "You and your sexual partner should consider embryo transfer first because it is safer." D) "Artificial insemination is useful only if your sexual partner has an allergy to your sperm."

Ans: A Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Apply Page: 145 Feedback: Donor sperm (alternative insemination by donor) is used if the man has no sperm. There is no evidence to support that the chance of conception is slight with artificial insemination. Embryo transfer is for the female partner who does not produce ova. Artificial insemination is useful for many different situations.

A woman is going to have in vitro fertilization. When preparing her for this, the nurse would make which statement? A) "It can be done with frozen donor sperm." B) "You will need to select a surrogate mother." C) "Most procedures are effective the first time tried." D) "This is dangerous if there is ovarian cancer in your family."

Ans: A Client Needs: Health Promotion and Maintenance Cognitive Level: Understand Page: 147 Feedback: Fresh or frozen sperm may be used. The success of in vitro fertilization is not related to the incidence of ovarian cancer in the family. Often more than one attempt is needed before successful implantation.

The nurse is asked to schedule a hysterosalpingogram. Which question would be most important for the nurse to ask the woman before scheduling the procedure? A) When do you expect your next menstrual flow? B) Are you allergic to any sedatives? C) What is your blood type and Rh factor? D) When did you have coitus last?

Ans: A Client Needs: Physiological Integrity: Physiological Adaptation Cognitive Level: Apply Page: 142 Feedback: Because a radiograph is involved, the procedure should be done in the few days following a menstrual flow when she is not apt to be pregnant.

Which statement would be most appropriate when explaining endometriosis as a cause of a woman's infertility? A) "Ovulation does take place; however, the misplaced endometrial tissue interferes with transport of the ovum." B) "Your uterine cervix fails to close because it is engorged with tissue." C) "Menstrual sloughing does not occur, so there is never a new base for embryo growth." D) "You do not ovulate because of endometrial implants on the ovaries."

Ans: A Client Needs: Physiological Integrity: Physiological Adaptation Cognitive Level: Apply Page: 143 Feedback: With endometriosis, endometrial tissue migrates into the fallopian tubes and peritoneum or other sites outside of the uterus. Ovulation occurs, but the egg may be trapped by the misplaced tissue.

A husband is worried he has an inadequate sperm count. Which circumstance would be most important for the nurse to ask about during his health history? A) if he works at a desk job B) if he eats a low-lipid diet C) if he jogs frequently D) if he takes a vitamin supplement

Ans: A Client Needs: Physiological Integrity: Physiological Adaptation Cognitive Level: Understand Page: 137 Feedback: Excessive heat to testicles, such as that created by sitting for long periods, may interfere with sperm production or survival.

A nurse is asked to teach a woman to take her basal body temperature daily to assess the time of ovulation. She can detect her day of ovulation, following ovulation, because her temperature will: A) increase a degree. B) decrease a degree. C) fluctuate a degree daily. D) no longer reflect basal body temperature.

Ans: A Client Needs: Physiological Integrity: Physiological Adaptation Cognitive Level: Understand Page: 140 Feedback: The effect of progesterone, released with ovulation, is to increase body temperature.

The female partner of a young couple is concerned about what the results of fertility tests might reveal. Which nursing diagnosis should the nurse use to plan care for this patient? A) Fear related to possible outcome of subfertility studies B) Deficient knowledge related to measures to promote fertility C) Anxiety related to the procedures necessary for fertility testing D) Situational low self-esteem related to the apparent inability to conceive

Ans: A Client Needs: Psychosocial Integrity Client Needs 2: Safe, Effective Care Environment: Management of Care Cognitive Level: Apply Page: 133 Feedback: The nursing diagnosis that would be the most appropriate to address concerns about the outcome of subfertility studies would be fear related to possible outcome. There is no information to support this patient having a knowledge deficit. The patient already had the testing so anxiety regarding these procedure processes would not be appropriate at this time. It is unknown if the patient will experience situational low self-esteem because the results of the fertility tests have not be disclosed to the patient.

The nurse is teaching a female to take her basal body temperature daily to assess the time of ovulation. What will the patient's body temperature reflect at the day of ovulation? A) Increase a degree. B) Decrease a degree. C) Fluctuate a degree daily. D) Spike one degree then drop.

Ans: A Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Analyze Page: 140 Feedback: At the time of ovulation, the basal body temperature can be seen to dip slightly (about 0.5ºF); it then rises to a level no higher than normal body temperature; it then stays at that level until 3 or 4 days before the next menstrual flow. This increase in basal body temperature marks the time of ovulation because it occurs immediately after ovulation. Upon ovulation, the basal body temperature will not decrease a degree, fluctuate, or spike and then drop.

The nurse instructs a couple on the process of basic fertility testing. Which patient statements indicate that teaching has been effective? Select all that apply. A) "The quality of the sperm will be looked at." B) "The sperm will be tested for adequate number." C) "A test will be done to determine if ovulation is occurring." D) "The importance of using in vitro fertilization will be discussed." E) "It will be determined if the sperm and eggs are able to meet correctly."

Ans: A, B, C, E Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Analyze Page: 137 Feedback: There are three parts to basic fertility testing. The sperm are analyzed for number and quality, ovulation is determined, and the environment for the sperm and egg to meet is analyzed. In vitro fertilization is not a part of basic fertility testing.

The nurse is planning an education session for couples planning to conceive. What should the nurse include to support the 2020 National Health Goals? Select all that apply. A) Highlight the importance of good nutrition. B) Include health promotion activities for both men and women. C) Stress the importance of having coitus every day while trying to conceive. D) Remind about safe sex practices to reduce sexually transmitted infections. E) Explain that conception rarely occurs in couples during the first year of trying.

Ans: A, B, D Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Apply Page: 133 Feedback: To support the 2020 National Health Goals, the nurse should focus on health promotion, early identification of problems that could lead to subfertility such as poor nutrition, and teaching patients about safer sex practices so the incidence of sexually transmitted infections and pelvic inflammatory disease can be reduced. It is best to have coitus every other day so that the sperm have adequate time to mature. Ninety percent of couples who have routine unprotected sex conceive within a year.

A female patient is willing to alter nutrition and activity status in an attempt to conceive. What teaching should the nurse provide to support this patient's desire? Select all that apply. A) Exercise 30 minutes each day. B) Plan to reduce body fat to less than 10%. C) Ingest vegetables that are high in fiber. D) Consciously reduce every day stressors. E) Add brown rice and dark bread to the diet.

Ans: A, C, D, E Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Apply Page: 140 Feedback: Nutrition, body weight, and exercise are all important for adequate ova production because they all influence the blood glucose/insulin balance. The patient should be instructed to exercise 30 minutes each day, ingest vegetables that are high in fiber, and reduce every day stressors. In addition, eating slowly digested carbohydrate foods such as brown rice and dark bread rather than food such as white bread, which has easily digested carbohydrates, cannot only increase fertility by keeping insulin levels balanced. Decreased body weight or a body/fat ratio of less than 10% can reduce pituitary hormones such as FSH and LH and halt ovulation.

A nurse is providing care to a woman who is to undergo surgery to remove fibroid tumors. The nurse teaches the woman about the procedure and what to expect after it. The nurse determines that the teaching was successful when the woman identifies which situation as most likely to occur after the surgery? A) Treatment with a testosterone B) Insertion of an intrauterine device C) Recommendation to become pregnant immediately D) Counseling to accept childfree living

Ans: B Client Needs: Physiological Integrity: Physiological Adaptation Cognitive Level: Analyze Page: 144 Feedback: Following uterine surgery, an IUD may be placed to prevent adhesions from forming and reducing the size of the cavity. The woman may be prescribed estrogen, not testosterone, for 3 months as another method to prevent adhesion formation. This treatment can be difficult for a woman to accept, because preventing pregnancy (using an IUD) is exactly what she does not want to do. Be certain she has a good explanation of the IUD's purpose and that it can be easily removed in about 1 month's time.

The nurse is assessing the health history of a male partner. Which data is most likely to be related to an infertility problem? A) 30 years of age B) employment as a taxi driver C) intercourse approximately every third day D) immunization against mumps as a child

Ans: B Client Needs: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analyze Page: 137 Feedback: Excessive testicular heat, which can occur from long periods of sitting, can limit sperm production and mobility.

The nurse completes instructing a female patient on the process of in vitro fertilization. Which statement indicates that patient teaching has been effective? A) "I will need to select a surrogate mother." B) "It can be done with frozen donor sperm." C) "Most procedures are effective the first time tried." D) "This is dangerous if there is ovarian cancer in my family."

Ans: B Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Analyze Page: 147 Feedback: Fresh or frozen sperm can be used for in vitro fertilization. A surrogate mother is not needed for this procedure. Often, more than one attempt is needed before successful implantation occurs. The success of in vitro fertilization is not related to the incidence of ovarian cancer in the family.

A couple, both age 22, want to know what they can do to improve the chances of conceiving. What should the nurse respond to this couple? A) Have coitus every day. B) Have coitus every other day. C) Consume a high-fat, low-protein diet. D) The female-superior position is the best for conception.

Ans: B Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Apply Page: 135 Feedback: Although frequent intercourse may stimulate sperm production, men need sperm recovery time after ejaculation to maintain an adequate sperm count. This is why coitus every other day, rather than every day, during the fertile period will probably yield faster results. A diet that is low in fat and moderate in protein is recommended. The male-superior position is the best for conception because the sperm will be closer to the cervical opening.

The nurse is assessing a male for sperm count. Which circumstance would be most important to ask about during the health history? A) Jogs frequently B) Works at a desk job C) Eats a low-lipid diet D) Takes a vitamin supplement

Ans: B Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Apply Page: 137 Feedback: Actions that directly increase scrotal heat, such as working at a desk job, may cause sperm counts to be lower compared with men whose occupations allow them to be ambulatory at least part of each day. Jogging, a low-lipid diet, and vitamin supplementation are not as important as physical posturing when beginning an analysis for a low sperm count.

Which definition best explains the term "subfertility/infertility"? A) failure to achieve pregnancy after 6 months of unprotected intercourse B) failure to achieve pregnancy after 1 year of unprotected intercourse C) inability to achieve pregnancy because of a known factor that prevents conception D) inability to achieve pregnancy following a previous viable pregnancy

Ans: B Client Needs: Safe, Effective Care Environment: Management of Care Cognitive Level: Remember Page: 133 Feedback: Infertility is the failure to achieve conception after 1 year of unprotected intercourse.

A man needs to bring a semen specimen in for analysis. Which of the following instructions would you give him? A) Obtain it immediately after voiding. B) Collect it immediately after coitus. C) Protect it against chilling. D) Dilute it with saline for transport.

Ans: C Client Needs: Health Promotion and Maintenance Cognitive Level: Apply Page: 138 Feedback: Extremes of body temperature (hot or cold) interfere with sperm viability.

A couple is undergoing fertility testing. The male partner is scheduled for semen analysis. When teaching the male partner about this procedure, the nurse would instruct him to refrain from sexual intercourse for which time frame before the analysis? A) 4 to 8 hours B) 12 to 24 hours C) 2 to 4 days D) at least 1 week

Ans: C Client Needs: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Apply Page: 138 Feedback: For a semen analysis, a client should be instructed to be sexually abstinent for 2 to 4 days before the analysis.

A female patient being treated for infertility is completing the third course of clomiphene citrate. What information should the nurse prepare for the patient in the event this course does not result in conception? A) Agencies that coordinate adoptions B) Strategies to improve sperm motility C) Additional options to achieve conception D) Informed consent for taking a fourth course of the medication

Ans: C Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Apply Page: 142 Feedback: Clomiphene citrate has a 5-day initial course. Then two additional courses of 5 days each can be provided. If the last course does not result in conception, the nurse should prepare additional options to achieve conception. It is premature to begin discussing adoption with the patient. Sperm motility is not an issue at this time. There is no need for informed consent for a fourth course of the medication.

How can pelvic inflammatory disease (PID) affect fertility? A) It causes anovulation because of interference with secretion of pituitary hormones. B) It causes changes in cervical mucus that make it less receptive to penetration by sperm. C) It causes sperm-agglutinating antibodies to be produced in the vagina. D) It interferes with the transport of ova because of tubal scarring.

Ans: D Client Needs: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Understand Page: 141 Feedback: Pelvic inflammatory disease, or infection of the fallopian tubes, results in scarring and adhesions of the tubes, leading to poor transport of ova.

The nurse is scheduling a female patient for a hysterosalpingogram. Which question would be most important to ask the patient before scheduling the procedure? A) When did you have coitus last? B) Are you allergic to any sedatives? C) What is your blood type and Rh factor? D) When do you expect your next menstrual flow?

Ans: D Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Apply Page: 142 Feedback: Because X-ray, which might be harmful to a growing pregnancy, is used, the procedure must be scheduled immediately following a menstrual flow when pregnancy could not be present. Asking about coitus, sedative allergies, or blood time and Rh factor are not the most important when scheduling the patient for a hysterosalpingogram.

An adolescent is diagnosed with pelvic inflammatory disease. It is believed to have been caused by abdominal adhesions after an appendectomy. What should the nurse explain to the patient about future success with fertility? A) "You won't ovulate normally." B) "Your body will reject any embryo implantation." C) "Your cervical mucus is changed, and sperm will be killed." D) "There's scarring that will make it really difficult for the eggs to pass through the tubes."

Ans: D Client Needs: Physiological Integrity: Physiological Adaptation Cognitive Level: Apply Page: 141 Feedback: Pelvic inflammatory disease could result from a ruptured appendix or from abdominal surgery that left adhesions in the tubes. About 12% of those who acquire PID will be left subfertile because of tubal scarring. Pelvic inflammatory disease does not affect ovulation. It will not cause the rejection of embryo transplantation, and it does not change the cervical mucus.

Which description best explains the hysterosalpingogram procedure? A) insertion of an endoscope through the posterior fornix to visualize the reproductive organs B) instillation of carbon dioxide through the cervix into the uterus and fallopian tubes C) passage of an endoscope through a small abdominal incision to inspect the reproductive organs D) radiograph of the uterus and fallopian tubes following introduction of a radiopaque medium through the cervix

Ans: D Client Needs: Physiological Integrity: Physiological Adaptation Cognitive Level: Understand Page: 142 Feedback: Hysterosalpingogram is a procedure to document the potency of the fallopian tubes through the use of a radiopaque medium.

The nurse has completed a fertility assessment on a couple and is preparing outcomes for care. Which statement indicates that the couple wants to continue with the process, regardless of the outcome? A) Couple interested in learning about other options to having a family. B) Couple wants to have a family but has limited resources for artificial methods. C) Couple states the desire to minimize disruptions in their normal activities for testing. D) Couple desires to continue with testing after it is determined that one partner is fertile.

Ans: D Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Analyze Page: 134 Feedback: The outcome statement that indicates the couple wants to continue with the process would be "couple desires to continue with testing after it is determined that one partner is fertile." The interest in learning about other options, having limited resources, and minimizing disruptions do not indicate that the couple desires to continue with testing.

What should the nurse include when explaining endometriosis as a cause for a female patient's infertility? A) "You do not ovulate because of endometrial implants on the ovaries." B) "Your uterine cervix fails to close because it is engorged with tissue." C) "Menstrual sloughing does not occur, so there is never a new base for embryo growth." D) "Ovulation does take place misplaced endometrial tissue interferes with transport of the ovum."

Ans: D Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Apply Page: 143 Feedback: Endometriosis refers to the implantation of uterine endometrium, or nodules, that have spread from the interior of the uterus to locations outside the uterus. If viable particles of endometrium enter a tube, they can cause tubal obstruction; growths on the ovaries can displace fallopian tubes away from the ovaries, preventing the entrance of ova into the tubes. Peritoneal macrophages, which are drawn to nodules of endometrium, can destroy sperm. Endometriosis does not affect ovulation, cervix competence, or menstruation.

Before signing the consent form for a myomectomy, the patient asks why an intrauterine device (IUD) is being inserted because the goal is to become pregnant. What should the nurse respond to the patient? A) After a myomectomy, an IUD will not prevent pregnancy. B) Pregnancy must be avoided for a year after a myomectomy. C) It is used to ensure an adequate menstrual blood flow occurs. D) It prevents the uterine sides from touching and forming new adhesions.

Ans: D Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Apply Page: 144 Feedback: During a myomectomy, an IUD may be inserted to prevent the uterine sides from touching and forming new adhesions. This treatment can be difficult for a woman to accept because preventing pregnancy through an IUD is exactly what she does not want to do. The IUD is not inserted to prevent pregnancy. An IUD will prevent pregnancy even after a myomectomy. The IUD is not used to ensure an adequate menstrual blood flow.

Why is fertility testing initiated with sperm analysis of the male partner? A) Asking the male partner to undergo diagnostic procedures is the best way to assess his interest in treatment of infertility. B) The man is found to be fertile in over 75% of couples with infertility problems. C) Male fertility testing is time-consuming and, therefore, should be initiated early. D) Sperm analysis is one of the easiest tests to complete.

Ans: D Client Needs: Safe, Effective Care Environment: Management of Care Cognitive Level: Apply Page: 137 Feedback: Because sperm analysis is noninvasive, it is one of the easiest tests (and, therefore, most cost-effective) to complete.

PREIMPLANTATION GENETIC DIAGNOSIS The individual retrieval of oocytes and their fertilization under laboratory conditions has led to close inspection and recognition of differences in sperm and oocytes. After the oocytes are fertilized in IVF and ZIFT procedures, the DNA of both sperm and oocytes can be examined for specific genetic abnormalities such as ?

Down syndrome or hemophilia

Testing for Ejaculation Concerns

Ejaculation concerns are identified by a sexual history. It may be difficult for a man to discuss this area of his life, especially if a nurse is female, so skillful patient interviewing technique is required.

OUTCOME EVALUATION

Examples of expected outcomes in this area include: -The patient rearranges work plans to manage the schedule of fertility testing by 1 month's time. -The couple verbalizes they understand their individual subfertility problem after preliminary testing. -The couple demonstrates a high level of self-esteem after fertility studies, even in the face of disappointing study outcomes. For a couple with the problem of subfertility, an evaluation is best if it is ongoing because, as circumstances around them change, so may their goals and desires. Until they can accept an alternative method of having children—adoption or an assisted reproductive technique such as alternative insemination (deposition of sperm into a woman's cervix or uterus) or in vitro fertilization (IVF; the union of sperm and ovum under laboratory conditions)—former plans to have children have been crushed.

As with alternative insemination, 1 month before the procedure, the woman is given

FSH to stimulate oocyte growth. Beginning about the 10th day of the menstrual cycle, the ovaries are examined daily by sonography to assess the number and size of developing ovarian follicles. When a follicle appears to be mature, a woman is given an injection of hCG, which causes ovulation in 38 to 42 hours. A needle is then introduced intravaginally and guided by ultrasound, and the oocyte is aspirated from its follicle. Because of the drugs given to induce ova maturation, many oocytes may ripen at once, and perhaps as many as 3 to 12 can be removed. The oocytes chosen are incubated for at least 8 hours to ensure viability. In the meantime, the male partner or donor supplies a fresh or frozen semen specimen. The sperm cells and oocytes are mixed and allowed to incubate in a growth medium. Genetic analysis to reveal chromosomal abnormalities or the potential sex can be completed at this point.

Nursing diagnoses related to subfertility are likely to focus on psychosocial issues associated with the inability to conceive and the potentially nerve-wracking process of fertility testing and management. Examples of possible diagnoses include:

Fear related to possible outcome of subfertility studies Situational low self-esteem related to the apparent inability to conceive Anxiety related to what the process of fertility testing will entail Deficient knowledge related to measures to promote fertility Anticipatory grieving related to failure to conceive or sustain a pregnancy Powerlessness related to repeated unsuccessful attempts at achieving conception Hopelessness related to perception of no viable alternatives to usual conception If required tests interfere with a couple's relationship (including sexual patterns), "sexual dysfunctio

EXPECTED OUTCOMES AND PLANNING

In establishing expected outcomes with a couple undergoing fertility testing and counseling, be certain the couple realizes even after the reason for their subfertility is identified, fertility may not be instantaneous. In some instances, a couple may need to change or modify their goals if tests begin to show what they first wanted—to have a child without medical intervention—is impossible. Participation in a support group may allow a couple to work through the stress fertility testing places on their lives. It is helpful to refer patients to online resources for further information and support

Testing for Anovulation

Many tests to detect ovulation can be completed independently by women at home, giving them both a sense of control over what is happening and the ability to learn more about the functioning of their bodies.

Testing for Sperm Transport Disorders

Sperm transport disorders are suspected when FSH and LH hormones, which stimulate the production of sperm, are adequate but the sperm count remains limited.

ASSESSMENT

Subfertility assessment used to require many months and many tests, all of which had the potential to interfere with a couple's self-image, self-esteem, and lifestyle. Today, a subfertility investigation is usually limited to only three assessments: semen analysis, ovulation monitoring, and tubal patency. Even with this more directed approach to evaluation, a nursing assessment often reveals that one or both partners feel inadequate or angry and frustrated by what has happened to them and their need to undergo testing. Questions such as "How do you feel about what has happened?" or "How do you think your partner feels about not being able to conceive?" may be enough to encourage partners to express these concerns. Talking with both partners together may be advantageous because they may feel more comfortable speaking about their problem together. It is important, however, to spend some time alone with each patient in case there is anything a partner wishes to discuss privately. This might be the only opportunity for one of them to ask that one "silly" question or voice a fear he or she believes is too foolish to ask or bring up in front of his or her partner.

A few women develop an ovarian hyperstimulation syndrome with IVF. What happens?

Their ovaries become swollen and painful and they may have accumulating abdominal and lung fluid. Women need to report these symptoms so ovarian stimulation can be halted until their ovaries return to normal; removing a number of oocytes and cryopreserving them can reduce the need for further stimulation with future procedures In some centers, nurse practitioners are the healthcare providers who complete oocyte removal and transfer.

UTERINE CONCERNS

Tumors such as fibromas (leiomyomas) may be a rare cause of subfertility if they block the entrance of the fallopian tubes into the uterus or limit the space available on the uterine wall for effective implantation. A congenitally deformed uterine cavity may also limit implantation sites, but this also is rare.

Testing for Tubal Patency

Ultrasound or X-ray imaging and direct visualization by a hysteroscope of fallopian tubes are all effective methods used to determine the patency of fallopian tubes.

To prepare for alternative insemination,

a woman receives an injection of clomiphene (Clomid) or FSH 1 month prior to the insemination so follicle growth of ova is stimulated and a day of ovulation can be predicted. On the selected day of insemination (confirmed by a serum analysis of progesterone), the sperm sample is instilled next to her cervix using a device similar to a cervical cap or diaphragm, or sperm are injected directly into the uterus using a flexible catheter Donors for alternative insemination are volunteers who have no history of disease and no family history of possible inheritable disorders. The blood type, or at least the Rh factor, can be matched with the woman's to prevent incompatibility. Sperm can be selected according to desired physical or mental characteristics if desired. If FSH was used to stimulate follicle growth, caution women that the chance for a multiple birth (twins or triplets) increases so she can be prepared for this

TEAMWORK & COLLABORATION Cheryl Carl is scheduled to have a sonohysterosalpingography. Which of the following instructions would the nurse want the care team members to know so patient teaching can be consistent? a. She may feel some mild cramping when the contrast medium is inserted. b. The X-ray of the uterus will reveal any fibroid tumors or adhesions present. c. She will not be able to conceive for at least 3 months after the procedure. d. Many women experience mild bleeding for up to 2 hours as an aftereffect.

a. She may feel some mild cramping when the contrast medium is inserted.

Assisted Reproductive Techniques

a.Alternative insemination b.Invitro Fertilization c.Gamete intrafallopian and zygote intrafallopian transfer d.Surrogate embryo transfer e.Preimplantation Genetic Diagnosis -If ovulation, sperm production, or sperm mobility problems cannot be corrected, assisted reproductive strategies are the next step for a couple to consider. Before beginning any of these procedures, urge a woman to be in excellent health by discontinuing smoking or recreational drug behaviors, ingesting a diet high in protein, and having a BMI within a normal range of 18.5 to 24.9. She probably also will have, if she has not already had them, tests for HIV and hepatitis C; a hormone profile including levels of FSH, LH, estrogen, and progesterone to test for ovarian reserves (whether ovaries have the capacity to produce multiple oocytes); as well as an intravaginal sonogram to visual usual structures

If the problem appears to be that sperm are immobilized by vaginal secretions due to an immunologic factor, the response can be reduced by

abstinence or condom use for about 6 months. However, to avoid this prolonged time interval (which is difficult for a couple who want to have a child immediately), washing of the sperm followed by IUI may be preferred.

Infection of the vagina can cause the pH of vaginal secretions to become

acidotic, thus limiting or destroying the motility of spermatozoa.

SURROGATE MOTHERS A surrogate mother is a woman who ?

agrees to carry a pregnancy to term for a subfertile couple or an LGBT couple. The surrogate may provide the ova, which is then impregnated by the man's sperm in the laboratory. In other instances, the ova and sperm both may be donated by the subfertile couple; in a third technique, both donor ova and sperm are used. Surrogate mothers are often friends or family members who assume the role out of friendship or compassion, or they can be referred to the couple through an agency or attorney and receive monetary reimbursement for their expenses. The subfertile couple can enjoy the pregnancy as they watch it progress in the surrogate.

Vaginal infections such as trichomoniasis and moniliasis tend to recur, requiring close supervision and follow-up. If the woman's sexual partner is the source of infection, and is therefore reinfecting her, the partner needs

antibiotic therapy as well. Caution women who are prescribed metronidazole (Flagyl) for a Trichomonas infection; although no studies have shown fetal malformations after its use, it may be teratogenic early in pregnancy and therefore should not be continued if the woman suspects she has become pregnant.

Surrogate embryo transfer is an

assisted reproductive technique for a woman who does not produce ova. For the process, the oocyte is donated by a friend, relative, or an anonymous donor ( The menstrual cycles of the donor and recipient are synchronized by administration of gonadotropic hormones. At the time of ovulation, the donor's ovum is removed by a transvaginal, ultrasound-guided procedure. The oocyte is then fertilized in the laboratory by the recipient woman's partner's sperm (or donor sperm) and placed in the recipient woman's uterus by embryonic transfer. Once pregnancy occurs, it progresses the same as an unassisted pregnancy

Exercising 30 minutes per day by walking or doing mild aerobics also helps to regulate what levels for ovulation to occur ?

blood glucose levels and increase fertility, complementing healthy eating habits. Stress may play a role in limiting ovulation as this may lower hypothalamic secretion of the gonadotropin-releasing hormone (GnRH), which then lowers the production of LH and FSH, which leads to anovulation.

CMA: Semen specimens should be kept at

body temperature during transportation. Patients can be advised to carry the specimen next to the body in an inside pocket to accomplish this goal.

GAMETE INTRAFALLOPIAN AND ZYGOTE INTRAFALLOPIAN TRANSFER In gamete intrafallopian transfer (GIFT) procedures,

both ova and sperm are instilled, within a matter of hours, using a laparoscopic technique, into the open end of a patent fallopian tube. Fertilization then occurs in the tube, and the zygote moves to the uterus for implantation. It requires at least one patent fallopian tube; it may be a preferred procedure by some couples because conception occurs in the fallopian tube and so is not contradictory to their religious beliefs.

PHYSICAL ASSESSMENT For women, a thorough physical assessment, including a

breast and thyroid examination, is necessary to rule out current illness. Of particular importance, again, are secondary sex characteristics, which indicate maturity and suggest good pituitary function A complete pelvic examination, including a Pap test , is needed to rule out anatomic disorders and infection

The ideal body weight to maintain is a BMI of 18.5 to 24.9. Eating slowly digested carbohydrate foods _______________________________________ rather than easily digested carbohydrate foods (e.g., white bread, cold breakfast cereals) can not only increase fertility by keeping insulin levels balanced but also may prevent gestational diabetes when a woman becomes pregnant

brown rice, pasta, dark bread, beans and fiber-rich vegetables asparagus, broccoli

SAFETY The Carls introduce themselves to the nurse as an "infertile" couple. As a safety measure, the nurse would want them to understand which of the following? a. Couples are not termed infertile until they have been trying to conceive for 2 years. b. Infertility can cause depression, so the couple should report any feeling of sadness. c. If their relationship is not monogamous, they still need to use safer sex practices. d. Infertility is related to antibiotic-resistant infections, so they need to be tested for these.

c. If their relationship is not monogamous, they still need to use safer sex practices.

QUALITY IMPROVEMENT Bob Carl asks the nurse several questions about the way in which his wife may be prepared for IUI. The clinical protocol for this procedure should include which of the following? a. The patient would undergo genetic testing prior to the procedure. b. The patient would wear a transdermal estrogen patch for 2 weeks prior to theprocedure. c. The patient would receive an injection of clomiphene (Clomid) or FSH 1month prior to the procedure. d. The patient would be prescribed bed rest for 48 to 72 hours following the procedure.

c. The patient would receive an injection of clomiphene (Clomid) or FSH 1month prior to the procedure.

PATIENT-CENTERED CARE Cheryl is unhappy that she waited until she bought a house to plan on having a child. What fact could the nurse cite to Cheryl? a. She should have begun trying to conceive by age 25 years, but her outcome should still be positive. b. She asked for testing well before the average woman, who asks at age 30 years. c. Waiting for 1 year after being unable to conceive is the average time for seeking help. d. We all make decisions in life that later on we wish we had not made.

c. Waiting for 1 year after being unable to conceive is the average time for seeking help.

EVIDENCE-BASED PRACTICE It is generally agreed that breast milk is the natural and best food for babies for the entire first year or at least until 6 months. To see if women who had babies through assisted reproductive techniques such as IVF choose to breastfeed as much as women having babies without an assisted technique, researchers interviewed 183 women who conceived using an assisted technique whether they breastfed their baby or not. Results showed that more women who conceived with the help of an assisted technique began breastfeeding than others (89.3% vs. 83.3%). By 3 months, however, a smaller number of women who had used an assisted technique were exclusively breastfeeding (46% vs. 57%); at 8 months, only 23% were still breastfeeding versus 57% of nonassisted women. Researchers attributed the decline in breastfeeding among women who used an assisted technique to more anxiety late in pregnancy and possibly to receiving suboptimal advice about assisted reproduction and breastfeeding from healthcare providers (Hammarberg, Fisher, Wynter, et al., 2011). Based on the previous study, assuming Cheryl Carl's IVF is successful and she becomes pregnant, what would the nurse advise her during her pregnancy? a."You may be unable to breastfeed because with IVF, you develop immune factors." b."You should breastfeed as this will increase your fertility for a second pregnancy." c."After your child's birth, you should be able to begin breastfeeding effectively." d."Try not to worry; worry causes hormones necessary for vaginal birth to decrease."

c."After your child's birth, you should be able to begin breastfeeding effectively."

Difficulty with tubal transport usually occurs because scarring has developed in the fallopian tubes, which is typically caused by

chronic salpingitis (chronic pelvic inflammatory disease). This could also result from a ruptured appendix or from abdominal surgery, which involved infection that spread to the fallopian tubes and left adhesion formation in the tubes. Complete tubal obstruction is the chief problem if a woman had a tubal ligation in years past but now wants to become pregnant.

Therapy for Anovulation If a disturbance in ovulation is identified as the subfertility concern, administration of GnRH is a possibility (this will stimulate the pituitary to secrete more FSH and LH). Therapy with

clomiphene citrate (Clomid) or letrozole (Femara), a newer drug, may also be used to stimulate ovulation S/E: Administration of either clomiphene citrate or gonadotropins may overstimulate an ovary, causing multiple ova to come to maturity, and possibly resulting in multiple births. Counsel women who receive these agents that this is a possibility

Additional testing for men, if warranted, can include urinalysis; a

complete blood count; blood typing, including Rh factor; a serologic test for syphilis; a test for the presence of HIV; erythrocyte sedimentation rate (an increased rate indicates inflammation); protein-bound iodine (a test for thyroid function); cholesterol level (arterial plaques could interfere with pelvic blood flow); follicle-stimulating hormone (FSH), luteinizing hormone (LH), testosterone levels

In vitro fertilization (IVF) is most often used for couples who have not been able to

conceive because the woman has obstructed or damaged fallopian tubes. It is also used when the man has oligospermia or a very low sperm count. IVF may also be helpful for couples when an absence of cervical mucus prevents sperm from entering the cervix or antisperm antibodies cause immobilization of sperm. In addition, couples with unexplained subfertility of long duration may be helped by IVF.

Age is related to subfertility. Because of this gradual decline in fertility, women who defer pregnancy into their late 30s are apt to have more difficulty

conceiving than their younger counterparts.

Uterine endometrial biopsy may be used to reveal an endometrial problem, such as a luteal phase defect. If the endometrium sample removed by biopsy resembles a

corkscrew (a typical progesterone-dominated endometrium) seen in the second half of a menstrual cycle, this suggests ovulation has occurred.

INFORMATICS Cheryl Carl is diagnosed as having endometriosis as a cause of her subfertility. The nurse would want her electronic health record to reflect the fact that this condition interferes with fertility because of which of the following? a. The ovaries stop producing estrogen and progesterone. b. The uterine cervix becomes very inflamed and swollen. c. Pressure on the pituitary leads to decreased FSH levels. d. Endometrial implants obstruct both of the fallopian tubes.

d. Endometrial implants obstruct both of the fallopian tubes.

Therapy for Lack of Tubal Patency If the subfertility problem is identified as tubal insufficiency from inflammation, the prescription of

diathermy or steroid administration may be helpful to reduce adhesions. Hysterosalpingography (instillation of a contrast dye under X-ray monitoring) can be attempted to see if the force of the dye insertion will break adhesions. Canalization of the fallopian tubes and plastic surgical repair (microsurgery) are other possible treatments. If peritoneal adhesions or nodules of endometriosis are holding the tubes fixed and away from the ovaries, these can be removed by laparoscopy or laser surgery

Although only a small amount of contrast medium is used, it does slightly

distend the uterus and tubes, possibly causing momentary painful uterine cramping. After the study, the small amount of contrast medium used drains out through the vagina. Although it is possible that the procedure could be therapeutic as well as diagnostic as the pressure of the solution could break up adhesions as it passes through the fallopian tubes, this is unlikely because the amount of contrast medium used is so small. Although extremely rare, the procedure carries a small risk of infection (a chlamydia screen before the procedure is usually advised); although unlikely, an allergic reaction to the contrast medium or embolism from the medium entering a uterine blood vessel could also occur.

For problems of abnormal uterine formation, such as a septate uterus, surgery is also available. However, these defects are usually related to

early pregnancy loss, not initial subfertility. Endometriosis can be treated both medically and surgically;

CHILD-FREE LIVING Child-free living is another option available to both fertile and subfertile couples. For many subfertile couples who have been through the rigors and frustrations of subfertility testing and unsuccessful treatment regimens, child-free living may

emerge as the option they finally wish to pursue. A couple in the midst of fertility testing may begin to reexamine their motives for pursuing pregnancy and may decide pregnancy and parenting are not worth the emotional or financial cost of future treatments. They may decide the additional stress of going through an adoption is not for them either, or they may simply decide children are not necessary for them to complete their family unit.

PID invasion of fallopian tubes is most apt to occur at the end of a menstrual period because menstrual blood provides such an

excellent growth medium for bacteria. There also is a loss of the normal cervical mucus barrier at this time, which increases the risk of initial invasion. When PID is left unrecognized and untreated, it enters a chronic phase, which causes the scarring that can lead to stricture of the fallopian tubes and the resulting fertility problem.

Therapy for Sperm Transport Disorders If sperm are not able to pass through the vas deferens because of obstruction, surgery to relieve the obstruction is extensive, costly, and may not have a positive outcome. A better solution can be

extracting sperm from a point above the blockage and injecting it into the vagina or uterus of the man's partner by intrauterine insemination (IUI)

Anovulation (absence of ovulation or release of ova from the ovary), the most common cause of subfertility in women, may occur from a

genetic abnormality such as Turner syndrome (hypogonadism), in which there is limited ovarian tissue available to produce ova. More often, it results from a hormonal imbalance caused by a condition such as hypothyroidism, which interferes with hypothalamus-pituitary-ovarian interaction. Ovarian tumors or polycystic ovary syndrome may also produce anovulation due to feedback stimulation on the pituitary. Chronic or excessive exposure to X-rays or radioactive substances, general ill health, poor diet, and stress may all contribute to poor ovarian function

Donor insemination can be used if the man has a known

genetic disorder he does not want to be transmitted to children or if a woman does not have a male partner. It is also a useful procedure for men who underwent a vasectomy but now wish to have children. In the past, men who underwent chemotherapy or radiation for testicular cancer had to accept being child-free afterward because they were no longer able to produce sperm. Today, sperm can be cryopreserved (frozen) in a sperm bank before radiation or chemotherapy and then used for alternative insemination afterward

If a sonogram reveals that a multiple pregnancy of more than two zygotes has been achieved, selective termination of

gestational sacs until only two remain may be recommended to help ensure the pregnancy will come to term. This is done by intra-abdominal injection of potassium chloride into the gestational sacs chosen to be eliminated

Parents who choose child-free living typically rate their marriage as

happier than for those with children probably because of the decreased expense involved and the availability of more free time, which allow them greater freedom in life

Child-free living can be as fulfilling as having children because it allows a couple more time to

help other people and contribute to society through personal accomplishments. It has advantages for a couple in that it also allows time for both members to pursue careers. They can travel more or have more time and money to pursue hobbies or continue their education. If a couple still wishes to include children in their lives in some way, many opportunities are available to do this through family connections (most parents welcome offers from siblings or other family members to share in childrearing), through volunteer organizations (such as Big Brother or Big Sister programs), or through local schools and town recreational programs.

cryptorchidism (undescended testes)

if surgical repair was not completed until after puberty or if the spermatic cord became twisted after the surgery.

The administration of corticosteroids to a woman may have some effect in decreasing sperm immobilization because it reduces her

immune response and antibody production.

Sterility is the

inability to conceive because of a known condition, such as the absence of a uterus.

Some states have specific laws regarding

inheritance, child support, and responsibility concerning children conceived by donor insemination, which may also limit whether a couple finds the technique desirable

Transvaginal Hydrolaparoscopy Transvaginal hydrolaparoscopy is begun with the

instillation of a paracervical local anesthetic block followed by introduction of a hysteroscope into an incision just behind the cervix through the cul-de-sac of Douglas into the peritoneal cavity. About 200 ml of normal saline is then introduced to move the bowel away from the uterus so the posterior wall of the uterus, the ovaries, and the fallopian tubes can be assessed. Tubal patency can be evaluated if, following the insertion of a small amount of dye into the cervix, it can be viewed exiting the fimbrial end of the tubes. At the end of the procedure, the fluid is drained from the peritoneal cavity; the small incision will heal without stitches

Testing and Therapy for Vaginal and Cervical Concerns If sperm do not appear to survive in vaginal secretions because secretions are too scant or tenacious, a woman may be prescribed

low-dose estrogen therapy to increase mucus production during days 5 to 10 of her cycle. Conjugated estrogen (Premarin) is a type of estrogen prescribed for this purpose. If a vaginal infection is present, the infection will be treated according to the causative organism based on culture reports

Actions that directly increase scrotal heat, such as working at a desk job or driving a great deal every day (e.g., salesmen, motorcyclists) may have

lower sperm counts compared with men whose occupations allow them to be ambulatory at least part of each day. Frequent use of hot tubs or saunas may also lower sperm counts. Maintaining an ideal body weight (body mass index [BMI] of 18.5 to 24.9) is a general preventative health measure. Excessive weight may alter testosterone production and sperm production

Spermatozoa must be produced and maintained at a temperature slightly

lower than body temperature to be fully motile. This is why the testes, in which sperm are produced and stored, are suspended in the scrotal sac away from body heat. -Any condition that significantly increases body temperature, such as a chronic infection from tuberculosis or recurrent sinusitis, has the potential to raise scrotal heat enough to lower a sperm count.

Procedure of Alternative or IUI is the instillation of sperm Either the male partner's sperm (alternative insemination by male partner) or donor sperm (alternative insemination by donor) can be used. These procedures are used if the :

male partner has no sperm or an inadequate sperm count, if a woman has a vaginal or cervical factor that interferes with sperm motility, or a woman has hormonal issues affecting fertility.

IVF is expensive (about $12,000 to $17,000 per cycle) and is available only at specialized centers. A complication of

maternal infection can occur if bacteria are introduced at any point in the transfer. Waiting to be accepted by a center's program and then waiting for the time to obtain the oocyte, allow for laboratory growth, and then pregnancy success is a major psychological strain. Couples report a feeling of social isolation during this time and weariness answering friends' and family's questions about when they will have a baby. Supply empathic support for them through this difficult time

If a myoma (fibroid tumor) or intrauterine adhesions are found to be interfering with fertility, a

myomectomy, or surgical removal of the tumor and adhesions, can be scheduled If the growth is small, this can be done by a hysteroscopic ambulatory procedure. During the procedure, an intrauterine device (IUD) may be inserted to prevent the uterine sides from touching and forming new adhesions; the woman may be prescribed estrogen for 3 months as another method to prevent adhesion formation. This treatment can be difficult for a woman to accept because preventing pregnancy (using an IUD) is exactly what she does not want to do. Be certain she has a good explanation of the IUD's purpose and that it can be easily removed in about 1 month's time.

Some couples, because they are unaware of the average length of time it takes to achieve a pregnancy, may worry they are subfertile when they are

not. On average, if they engage in coitus about four times per week, 65% to 75% of couples will conceive within 6 months; 90% within 12 months. These periods will be longer if sexual relations are less frequent

OBSTRUCTION OR IMPAIRED SPERM MOTILITY Diseases such as mumps orchitis (testicular inflammation and scarring due to the mumps virus), epididymitis (inflammation of the epididymis), and infections such as gonorrhea or ascending urethral infection can result in this type of

obstruction because adhesions form and occlude sperm transport Congenital stricture of a spermatic duct may occasionally be seen. Benign hypertrophy of the prostate gland occurs in most men beginning at about 50 years of age. Pressure from the enlarged gland on the vas deferens can then interfere with sperm transport. Infection of the prostate, through which the sperm and seminal fluid must pass, or infection of the seminal vesicles (spread from a urinary tract infection) can change the composition of the seminal fluid enough to reduce sperm motility.

Unexplained Subfertility In a small percentage of couples, no known cause for subfertility can be discovered. It may be that the problem of

one partner alone is not significant, but when combined with a small problem in the other partner, together, these become sufficient to create subfertility. It is obviously discouraging for couples to complete a fertility evaluation and be told their inability to conceive cannot be explained. Offer active support to help the couple find alternative solutions at this point, such as continuing to try to conceive, using an assisted reproductive technique, choosing to adopt, or agreeing to a child-free life.

The sperm analysis may need to be repeated after 2 or 3 months because spermatogenesis is an

ongoing process and 30 to 90 days is needed for new sperm to reach maturity. If patients are reluctant to have their sperm counted at a healthcare facility, they have the option to use various self-test kits to test sperm motility at home. These kits are available online. If the man has a vas deferens obstruction, sperm can be obtained by testes biopsy.

Erectile dysfunction

or the inability to achieve an erection (formerly called impotence), which may occur from psychological problems; diseases such as a cerebrovascular accident, diabetes, or Parkinson disease; use of certain antihypertensive agents; as well as the discontinuation of finasteride, a drug used for male pattern baldness , may result in erectile dysfunction. This condition is primary if the man has never been able to achieve erection and ejaculation and secondary if the man was able to achieve ejaculation in the past but now has difficulty. Erectile dysfunction can be a difficult problem to solve if it is associated with stress because this is not easily relieved.

The most frequent cause, however, for anovulation is naturally occurring variations in ovulatory patterns or polycystic ovary syndrome, a condition in which the

ovaries produce excess testosterone, thus lowering FSH and LH levels, which then causes irregular and unpredictable menstrual cycles

Decreased body weight or a body fat ratio of less than 10%, as may occur in female athletes such as competitive runners or in women who are excessively lean or anorexic, can reduce

pituitary hormones such as FSH and LH and halt ovulation (termed hypogonadotrophic hypogonadism)

progesterone or LH may be prescribed to a woman following IVF if it is believed she will not

produce enough on her own to support implantation. Proof the zygote has implanted can be demonstrated by a routine serum pregnancy test as early as 11 days after transfer.

If the problem of subfertility appears to be a luteal phase defect, this can be corrected by

progesterone vaginal suppositories begun on the third day of a woman's temperature rise and continued for the next 6 weeks (if pregnancy occurs) or until a menstrual flow begins

Therapy for Ejaculation Concerns Solutions for erectile dysfunction include

psychological or sexual counseling as well as the use of a phosphodiesterase inhibitor, such as sildenafil (Viagra) or tadalafil (Cialis) Dapoxetine, a short-acting selective serotonin reuptake inhibitor, is a drug that has been developed especially for the treatment of premature ejaculation and shows good results when taken about 1 hour before planned coitus

PHYSICAL ASSESSMENT For men, i mportant aspects of this include whether secondary sexual characteristics, such as

pubic hair, are present as well as no genital abnormalities, such as the absence of a vas deferens or the presence of undescended testes or a varicocele (enlargement of a testicular vein), are present. A hydrocele (a collection of fluid in the tunica vaginalis of the scrotum) is rarely associated with subfertility but should be documented if present.

HEALTH HISTORY While obtaining health histories, be certain to take time with each partner individually and as a couple to encourage

questions and to discuss overall attitudes toward sexual relations, pregnancy, and parenting. A frank discusion centered on resolving the couple's fears and clearing up any long-standing confusion or misinformation will help to set a positive tone for future interactions and, hopefully, establish a feeling of trust and increased self-esteem. Talking with both partners can also help them clarify their feelings about subfertility and why they are seeking help in this area of their life

Men who are exposed to ______________ _______________ in their work environment should be provided with adequate protection of the testes.

radioactive substances

Because conception through alternative insemination takes an average of 6 months to achieve, and some couples may have religious or ethical beliefs that prohibit the use of sperm from either the male partner or a donor, it may not be

right for every couple. Also, because it can be a discouraging process for a couple to have to wait 6 months (or longer) to see results, couples may need support to continue the technique.

Testing for Sperm Number and Availability A number of common tests, such as

semen analysis and sperm motility, help to identify whether adequate sperm are present for conception.

Ovulation Monitoring The fastest way to investigate if ovulation is occurring is to measure the woman's what ?

serum progesterone level during the luteal phase of her menstrual cycle (about day 21 to day 28 of a typical cycle). If this is elevated, it implies a corpus luteum has formed or ovulation has occurred. ADV:The least costly way to determine a woman's ovulation pattern is to ask her to record her basal body temperature (BBT) for at least 4 months. To determine this, a woman takes her temperature each morning, before getting out of bed or engaging in any activity, eating, or drinking, using a special BBT or tympanic thermometer. the BBT can be seen to dip slightly (about 0.5°F), it then rises to a level about 1 degree higher than her preovulation temperatures and then stays at that level until 3 or 4 days before the next menstrual flow. This increase in BBT marks the time of ovulation because it occurs immediately after ovulation (and at the beginning of the luteal phase of the menstrual cycle, which can occur only if ovulation has occurred). If the temperature rise does not last at least 10 days, it suggests a woman has a luteal phase defect (progesterone is not being produced long enough in a cycle so adequate endometrium for implantation can be laid down)

Women who are using oral, injectable, or implanted hormones for contraception may have difficulty becoming pregnant for

several months after discontinuing these medications, although most women return to normal cycles within 1 month

One disadvantage of using cryopreserved sperm is that it tends to have

slower motility than unfrozen specimens. However, although the rate of conception may be lower from this source, there appears to be no increase in the incidence of congenital anomalies in children conceived by this method, and sperm remain viable even after years of storage

A sonohysterosalpingogram is a

sonographic examination of the fallopian tubes and uterus using an ultrasound contrast agent introduced into the uterus through a narrow catheter inserted into the uterine cervix followed by intravaginal scanning. Occurs: If the tubes are patent, they will fill with the contrast medium and be detailed on the ultrasound screen. contraindication: if infection of the vagina, cervix, or uterus is present (infectious organisms might be forced through the tubes into the pelvic cavity); it is usually scheduled just following a menstrual flow when a woman could not be pregnant.

A hysterosalpingogram is similar to a

sonohysterosalpingogram except a radiopaque contrast medium is used and the fallopian tubes are revealed by X-ray. This procedure uses more contrast medium than with the sonogram technique so the force of the injected solution may actually break up tubal adhesions, and thus may be therapeutic as well as diagnostic. Because an X-ray is used, which might be harmful to a growing pregnancy, the procedure must be scheduled immediately following a menstrual flow when pregnancy could not be present.

Testing for Uterine Concerns

tests to determine if a uterine concern is leading to subfertility include a sonogram or hysteroscopy to view the structure of the uterus, blood work to analyze for hormones, and perhaps an endometrial biopsy

Pelvic inflammatory disease (PID) is infection of the pelvic organs:

the uterus, fallopian tubes, ovaries, and their supporting structures. The initial source of the infection is usually a sexually transmitted disease such as chlamydia or gonorrhea.

In secondary subfertility,

there has been a previous viable pregnancy but the couple is unable to conceive at present.

VAGINAL AND CERVICAL CONCERNS At the time of ovulation, the cervical mucus is thin and watery and can be easily penetrated by spermatozoa for a period of 12 to 72 hours. If coitus is not synchronized with this time, the cervical mucus may be too thick to allow spermatozoa to penetrate the cervix. Infection or inflammation of the cervix (erosion) can also cause cervical mucus to

thicken so much that spermatozoa cannot penetrate it easily or survive in it. A stenotic cervical os or obstruction of the os by a polyp may further compromise sperm penetration. This is rarely enough of a problem to be the sole cause of subfertility, however. A woman who has undergone dilatation and curettage (D&C) procedures several times or cervical conization (cervical surgery) should be evaluated in light of the possibility that scar tissue and tightening of the cervical os has occurred.

Anomalies of the penis, such as hypospadias (urethral opening on the ventral surface of the penis), epispadias (urethral opening on the dorsal surface), or Peyronie disease (a bent penis) can cause sperm to be deposited

too far from the sexual partner's cervix to allow optimal cervical penetration. Extreme obesity in a male may also interfere with effective penetration and deposition

Couples who engage in coitus daily, hoping to cause early impregnation, may actually have more difficulty conceiving than those who space coitus every other day. This is because ?

too-frequent coitus can lower a man's sperm count to a level below optimal fertility.

GAMETE INTRAFALLOPIAN AND ZYGOTE INTRAFALLOPIAN TRANSFER Zygote intrafallopian transfer (ZIFT) is similar to IVF in that the egg is fertilized in the laboratory, but like GIFT, the fertilized egg is

transferred by laparoscopic technique into the end of a waiting fallopian tube. Although available, this technique is little used today because of the extensive laparoscopic technique needed.

Endometriosis refers to the implantation of

uterine endometrium, or nodules, that have spread from the interior of the uterus to locations outside the uterus The occurrence of endometriosis may indicate the endometrial tissue has different or more friable qualities than usual (perhaps due to a luteal phase defect) and therefore is a type of endometrium that also does not support embryo implantation as well as usual.

Hysteroscopy is visual inspection of the

uterus through the insertion of a hysteroscope (a thin hollow tube) through the vagina, cervix, and into the uterus. This is helpful to further evaluate uterine adhesions, malformations, or other abnormalities such as fibroid tumors or polyps that were discovered on sonogram imaging. Women are screened for chlamydia before the examination to avoid introduction of bacteria into the uterus.

Sperm Penetration Assay and Antisperm Antibody Testing For impregnation to take place, sperm must be mobile enough to navigate the vagina, uterus, and a fallopian tube to reach the ova. Although sperm penetration studies are rarely necessary, they may be scheduled to determine ?

whether a man's sperm, once they reach an ovum, can penetrate it effectively. With the use of an assisted reproductive technique such as IVF, poorly mobile sperm or those with poor penetration can be injected directly into a woman's ovum under laboratory conditions (intracytoplasmic sperm injection), bypassing the need for sperm to be fully mobile.

Polycystic ovary syndrome is associated with metabolic syndrome, which is diagnosed in patients with:

• Waist circumference of 35 in. or more in women • Fasting blood glucose over 100 mg/dl • Serum triglycerides over 150 mg/dl • Blood pressure over 135/85 mmHg • High-density lipoprotein cholesterol over 50 mg/dl • Development of hirsutism (unwanted body hair)

Nursing Care Planning to Empower a Family Q. Cheryl Carl asks you, "Is there anything we can do to help increase our chances of conception?" A. The following are time-honored suggestions to help aid conception:

• Determine the time of ovulation through the use of basal body temperature or analysis of cervical secretions and then plan sexual relations for every other day around the time of ovulation. • Although frequent intercourse may stimulate sperm production, men need sperm recovery time after ejaculation to maintain an adequate sperm count. This is why coitus every other day, rather than every day, during the fertile period will probably yield faster results. • The male-superior position is the best position for coitus to achieve conception because it places sperm closest to the cervical opening. • The male should try for deep penetration so ejaculation places sperm as close as possible to the cervix. Elevating a woman's hips on a small pillow can facilitate sperm being deposited near the opening to the cervix. • A woman should remain on her back with knees drawn up for at least 20 minutes after ejaculation to help sperm remain near the cervix. • Don't use douching or lubricants before or after intercourse so vaginal pH is unaltered, which can interfere with sperm mobility. • Eat a diet high in slowly digested carbohydrates, low in saturated or trans fats, and moderate in protein. • Maintain a body weight that results in a body mass index between 18.5 and 24.9. • Exercise about 30 minutes per day to help keep blood glucose and insulin levels stabilized. • Choose a new activity the two of you can do together, such as learning how to bowl or ballroom dance, so you create an activity separate from planning a baby. This not only helps to pass the time in a positive way but also offers a positive outlook for a month when you don't conceive.

Factors That Cause Male Subfertility The factors that most commonly lead to male subfertility include:

• Disturbance in spermatogenesis (production of sperm cells) • Inadequate production of FSH and LH in the pituitary, which stimulates the production of sperm • Obstruction in the seminiferous tubules, ducts, or vessels, which prevent the movement of spermatozoa • Qualitative or quantitative changes in the seminal fluid, which prevent sperm motility (movement of sperm) • Development of autoimmunity, which immobilizes sperm • Problems in ejaculation or deposition, which prevents spermatozoa from being placed close enough to a woman's cervix to allow ready penetration and fertilization • Chronic or excessive exposure to X-rays or radioactive substances, general ill health, poor diet, and stress, all of which may interfere with sperm production

Initial History Taking for the Subfertile Couple History taking for women should include:

• Her general health • Nutrition, including an adequate source of folic acid and avoidance of trans fats • Current or past reproductive tract problems, such as infections • Past history of a childhood cancer treated with radiation that might have reduced ovarian function or any exposure to occupational hazards, such as X-rays or toxic substances • Abdominal or pelvic operations that could have compromised blood flow to pelvic organs • Overall health, emphasizing endocrine problems such as galactorrhea (breast nipple secretions) or symptoms of thyroid dysfunction (always tired or hyperactive) • If she is from a country that allows the practice, ask about female circumcision because this can leave vulvar scars that interfere with penetration and deposition of sperm close to the cervix • History of contraceptive use • Past pregnancies, miscarriages, or abortions • If she can detect ovulation through such symptoms as breast tenderness, midcycle "wetness," or lower abdominal pain (mittelschmerz) • The use of douches or intravaginal medications or sprays that could interfere with vaginal pH • A menstrual history, including age of menarche; length, regularity, and frequency of menstrual periods; amount of flow; and any difficulties the woman experiences, such as dysmenorrhea or premenstrual dysphoric disorder (PDD)

Initial History Taking for the Subfertile Couple History taking for men should include:

• His general health • A typical 24-hr food intake, including alternative therapies such as herbs and whether he ingests alcohol, uses recreational drugs, or smokes or uses tobacco • If he had a congenital health problem, such as hypospadias or cryptorchidism (defined later) or a past illness such as mumps orchitis, urinary tract infection, or a sexually transmitted disease that could affect fertility • If he ever had radiation to his testes because of childhood cancer, X-rays, or an industrial accident • If he had an operation such as surgical repair of a hernia or torsion of the testes, which could have compromised the blood supply to his testes • If he has any current illness, particularly an endocrine one or a low-grade infection • If his job or lifestyle involves sitting all day • What his sexual practices are, such as frequency of coitus, masturbation, coital positions used, or if he ever experiences failure to achieve ejaculation • What past contraceptive measures, if any, he has used or if he has children from a previous relationship

Factors That Cause Female Subfertility The factors that cause subfertility in women are analogous to those causing subfertility in men:

• Limited production of FHS or LH, which interfere with ova growth • Anovulation (faulty or inadequate expulsion of ova) • Problems of ova transport through the fallopian tubes to the uterus • Uterine factors, such as tumors or poor endometrial development • Cervical and vaginal factors, which immobilize spermatozoa • Poor nutrition, increased body weight, and lack of exercise, which may compound these problems

Other conditions that may inhibit sperm production include:

• Past trauma to the testes • Surgery on or near the testicles that has resulted in impaired testicular circulation • Endocrine imbalances, particularly of the thyroid, pancreas, or pituitary glands • Drug use or excessive alcohol use • Environmental factors, such as exposure to X-rays or radioactive substances

The sperm count is the number of sperm in a single ejaculation or in a milliliter of semen. The minimum sperm count considered normal has:

• Thirty-three to 46 million sperm per milliliter of seminal fluid, or 50 million per ejaculation • Fifty percent of sperm that are motile • Thirty percent that are normal in shape and form