Infertility/Contraception
menorrhagia
excessive menstrual bleeding
Behavioral contraceptive method includes
- Abstinence - Fertility awareness - Based methods - Withdrawal (coitus interruptus) - Lactational Amenorrhea Method (LAM)
Fertility Awareness examples
- Cervical Mucus Ovulation Method - Basal Body Temperature - Symptothermal Method - Standard Days Method
A woman is 40 years old and a heavy smoker. She has a single sexual partner but has very irregular menstrual cycles. She wants a highly reliable contraceptive. Which method would be the best recommendation?
- a diaphragm and spermicide Women over 40 who smoke should not take ovulation suppressants; irregular menstrual cycles make natural methods difficult; women over 40 may have vaginal dryness, so a spermicidal suppository would not be activated.
Clomiphene citrate (Clomid)
A nonsteroidal synthetic antiestrogen used to induce ovulation. Clomid is typically discontinued after three cycles of use - Considerations: Nurse can advise the couple to have intercourse every other day for 1 wk starting after day 5 of medication
LAPAROSCOPY
A laparoscopy is usually performed early in the menstrual cycle. It is not part of the routine infertility evaluation. It is used when abnormalities are found on the ultrasound or the hysterosalpingogram. Because of the added risks of surgery, the need for anesthesia, and operative costs, it is only used when clearly indicated. During the procedure, an endoscope is inserted through a small incision in the anterior abdominal wall. Visualization of the peritoneal cavity in an infertile woman may reveal endometriosis, pelvic adhesions, tubal occlusion, fibroids, or polycystic ovaries (Kodaman, 2015).
Essure
A tiny coil (Essure) is introduced and released into the fallopian tubes through the cervix. The coil promotes tissue growth in the fallopian tubes, and over a period of 3 months, this growth blocks the tubes. The buildup of tissue creates a barrier that keeps sperm from the reaching the ovum, thus preventing conception (Thurkow, 2015). This less-invasive technique uses a hysteroscopy under local anesthesia in an office setting. Sterilization does not occur immediately after this procedure, so women must be educated to use additional contraception for 3 months until permanent tubal occlusion is verified.
4 DIFFERENT CONTRACEPTIVE METHODS ARE:
Behavioral, Barrier, Hormonal, and Permanent
Chemical Barriers
Called spermicides, may be used with/along mechanical barrier devices - They come in jellies, foam, cream, suppositories, and vaginal films
Fertility drugs
Clomiphene citrate (Clomid), Human menopausal gonadotropin (HMG); Pergonal, Artificial insemination,
Barrier Contraceptive Methods Include
Condom (Male and Female) Diaphragm Cervical Cap Sponge
Prime points to stress-concerning ECs are:
ECs do not offer any protection against STIs or future pregnancies. ECs should not be used in place of a regular birth control method, because they are less effective. ECs may delay the next menses, so evaluation for pregnancy is needed if menses does not occur within 3 weeks after EC use. Report any severe abdominal pain to health care provider immediately. ECs are regular birth control pills given at a higher dose. ECs are contraindicated during pregnancy
Donor oocytes or sperm
Eggs or sperm are retrieved from a donor and the eggs are inseminated; resulting embryos are transferred via IVF Recommended for women older than 40 yrs and those with poor-quality EGG CONSIDERATIONS: Nurse needs to support couple in their ethical/religious discussions prior to deciding
As ovulation approaches, the mucus becomes more abundant, clear, slippery, and smooth; it can be stretched between two fingers without breaking. Under the influence of estrogen, this mucus looks like egg whites. It is called spinnbarkeit mucus - Around this time it means that you are?
Fertile, so if you want to become pregnant now is the chance.
HOME OVULATION PREDICTOR KITS
Home ovulation predictor kits contain monoclonal antibodies specific for LH and use the ELISA test to determine the amount of LH present in the urine. A significant color change from baseline indicates the LH surge and presumably the most fertile day of the month for the woman.
HYSTEROSALPINGOGRAPHY
Hysterosalpingography is the gold standard in assessing patency (being open and unobstructed) of the fallopian tubes. Fallopian tube obstruction is among the most common causes of female factor infertility. Ultrasonography and magnetic resonance imaging (MRI) are used in this assessment. In hysterosalpingography, 3 to 10 mL of an opaque contrast medium is slowly injected through a catheter into the endocervical canal so that the uterus and tubes can be visualized during fluoroscopy and radiography. If the fallopian tubes are patent, the dye will ascend upward to distend the uterus and the tubes and will spill out into the peritoneal cavity (Hemingway & Trew, 2015) (Fig. 4.4).
Assisted reproductive technologies
IVF, GIFT, ICSI, DONOR OOCYTE OR SPERM, PGD, GESTATIONAL CARRIER (SURROGATE)
Gestational carrier (surrogacy)
Laboratory fertilization takes place and embryos are transferred to the uterus of another woman, who will carry the pregnancy. Or intrauterine insemination can be done with the male sperm Medical-legal issues have resulted over the "true ownership" of the resulting infant CONSIDERATIONS: Nurse should encourage an open discussion regarding implications of this method with the couple
Human menopausal gonadotropin (HMG); Pergonal
Induces ovulation by direct stimulation of ovarian follicle - Considerations: Nurse can advise the couple to have intercourse every other day for 1 wk starting after day 5 of medication
Copper-bearing IUS (ParaGard-TCu-380A)
Inserted within 5 days after unprotected sexual episode Can be left in for long-term contraception (10 yrs)
Vasectomy
It is usually performed under local anesthesia in a urologist's office, and most men can return to work and normal activities in a day or two. The procedure involves making a small incision into the scrotum and cutting the vas deferens, which carries sperm from the testes to the penis - Immediate risks include infection, hematoma, and pain. After vasectomy, semen no longer contains sperm. This is not immediate, though, and the man must submit semen specimens for analysis 8 to 16 weeks after a vasectomy until two specimens show that no sperm is present. When the specimen shows azoospermia, the man's sterility is confirmed
Intracytoplasmic sperm injection (ICSI)
One sperm is injected into the cytoplasm of the oocyte to fertilize it. Indicated for male factor infertility CONSIDERATIONS: Nurse needs to inform the male that sperm will be aspirated by a needle through the skin into the epididymis
Gamete intrafallopian transfer (GIFT)
Oocytes and sperm are combined and immediately placed in the fallopian tube so fertilization can occur naturally Requires laparoscopy and general anesthesia, which increases risk CONSIDERATIONS: Nurse needs to inform couple of risks and have consent signed
In vitro fertilization (IVF)
Oocytes are fertilized in the lab and transferred to the uterus Usually indicated for tubal obstruction, endometriosis, pelvic adhesions, and low sperm counts CONSIDERATIONS: Nurse advises woman to take medication to stimulate ovulation so the mature ovum can be retrieved by needle aspiration
Hormonal Contraceptive Methods Include
Oral Contraceptive Injectable Contraceptive Intrauterine Contraceptive Emergency Contraceptive
WARNINGS FOR INTRAUTERINE SYSTEM USERS OF POTENTIAL COMPLICATIONS
P = Period late, pregnancy, abnormal spotting or bleeding A = Abdominal pain, pain with intercourse I = Infection exposure, abnormal vaginal discharge N = Not feeling well, fever, chills S = String length shorter or longer or missing
CLOMIPHENE CITRATE CHALLENGE TEST
The clomiphene citrate challenge test is used to assess a woman's ovarian reserve (ability of her eggs to become fertilized). FSH levels are drawn on cycle day 3 and on cycle day 10 after the woman has taken 100 mg clomiphene citrate on cycle days 5 through 9. If the FSH level is greater than 15, the result is considered abnormal and the likelihood of conception with her own eggs is very low (Schuiling & Likis, 2016).
Artificial insemination
The insertion of a prepared semen sample into the cervical os or intrauterine cavity Enables sperm to be deposited closer to improve chances of conception. Husband or donor sperm can be used - Considerations: Nurse needs to advise couple that the procedure might need to be repeated if not successful the first time
Permanent Contraceptive Methods Include
Tubal Ligation or Essure for Women Vasectomy for Men
Preimplantation genetic diagnosis (PGD)
Used to identify genetic defects in embryos created through IVF before pregnancy. This is done specifically when one or both genetic parents have a known genetic abnormality and testing is performed on an embryo to see if it also carries a genetic abnormality CONSIDERATIONS: Nurse should inform couple about this option and support them until test results return
A nurse is teaching a couple about how to use a condom. The nurse determines the couple can properly apply the condom when they state that it should be applied at which time to be most effective?
before penile-vulvar contact Explanation: Some sperm may be released with pre-ejaculation semen, so a condom needs to be used with any penile-vulvar contact. It is best applied when the penis is erect. It is not necessary to apply an hour in advance. Waiting until after ejaculation would not be effective. It can be part of the foreplay, however, the primary goal is to prevent sperm from entering the vagina, so it should be in place before any penile-vulvar contact occurs.
Mechanical Barrier Contraceptives
condoms, diaphragms, cervical caps, and sponges - these devices are placed over the penis or cervix to physically obstruct the passage of sper, through the cervix
A young couple is exploring their contraceptive options and are curious about using an intrauterine contraceptive device. The nurse explains that there are two types, one that uses hormones and one that uses
copper. Explanation: Currently three intrauterine contraceptives are available in the United States: the copper ParaGard-TCu-380A, the levonorgestrel-releasing intrauterine system (LNG-IUS) marketed as Mirena, and another LNG-IUD marketed as Skyla. The ParaGard-TCu-380A is approved for 10 years of use and is nonhormonal. Its mechanism of action is based on the release of copper ions, which alone are spermicidal. Additionally, the device causes an inflammatory action leading to a hostile uterine environment.
Laparoscopic, abdominal, and hysteroscopic methods of
female sterilization are available in the United States
essure advantages over conventional tubal ligation
general anesthesia and incisions are not needed, thereby increasing safety, lowering costs, and improving access to sterilization
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:
increase a degree - The effect of progesterone, released with ovulation, is to increase body temperature.
The nurse informs the client that a diaphragm is an example of which type of contraception?
mechanical barrier Explanation: The diaphragm is an example of a mechanical barrier. It is a circular rubber disk placed over the cervix before intercourse.
What does fertility awareness use ?
physical signs and symptoms that change with hormone fluctuations throughout a woman's menstrual cycle to predict a woman's fertility
Which description best explains the hysterosalpingogram procedure?
radiograph of the uterus and fallopian tubes following introduction of a radiopaque medium through the cervix
A couple comes to the clinic and states to the nurse, "I don't think we are ever going to be able to have children. We have been trying but have had no luck." What assessments does the nurse anticipate will be performed for this couple? Select all that apply.
semen analysis ovulation monitoring tubal patency Explanation: Today, a subfertility investigation usually is limited to three assessments: semen analysis, ovulation monitoring, and tubal patency.
Tubal Ligation
the sterilization procedure for women, can be performed postpartum, after an abortion, or as an interval procedure unrelated to pregnancy - Mini-laparotomies and laparoscopies are the two most common techniques. In the laparoscopy procedure, the abdomen is filled with carbon dioxide gas so that the abdominal wall balloons away from the tubes provide a view of the fallopian tubes. They are grasped and sealed with a cauterizing instrument or with rings, bands, or clips or cut and tied