CH 7
child free living for what kinds of people
fertile and subfertile it allows a couple more time to help other people and contribute to society through personal accomplishments
sperm count
#of sperm in a single ejaculation or in a milliliter of semen
therapy for lack of tubal patency: hysterosalpinography
(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 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
Male factors that contribute to subfertility are inadequate sperm count, obstruction or impaired sperm motility, and problems with ejaculation. Female factors that cause subfertility are problems with ovulation, cervical or tubal transport, or impaired implantation.
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solutions for ED and premature ejaculation
-psychological or sexual counseling -use of phosphodiesterase inhibitor like sildenafil (Viagra) or tadalafil (Cialis) -Dapoxetine, an SSRI short acting is a drug that has been developed ESPECIALLY for tx of premature ejaculation and shows good results when taken about 1 hour before planned coitus
if a woman is younger than 35 it is suggested she have an evaluation after...If older than 35
1 year of subfertility 6 months
ejaculation for analysis should produce a MINIMUM of how much semen and spermatazoa
1.4-1.7 33-46 million spermatozoa per mL of fluid
if BBT temp does not last at least...
10 days, it suggests a woman has a luteal phase defect (progesterone not being produced long enough in a cycle so adequate endometrium for implantation can be laid down)
$ IVF
12 to 17 grand per cycle available at specialized centers
if an endometrial biopsy is required it is done...how is it done?
2-3 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. A woman may experience mild-to-moderate discomfort from maneuvering the instruments with maybe 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. CONTRAINDICATED IF PREGNANCY SUSPECTED OR PID OR CERVICITIS educate may see small amount vaginal spotting after follow up PCP if temp greater than 101, large bleeding or passes clots
After fertilization of the chosen oocytes occurs, the zygotes formed almost immediately begin to divide and grow...after how many hours will they undergo first cell division
40
BPH occurs what age
50
clomiphene citrate dosage
50 mg orally 5 days (started anytime if no menstrual flow has occurred recently or about the fifth day of the cycle if menstrual flow is occurring). If ovulation does not occur with this initial therapy, the drug can be followed by a prescription of 100 mg/day for 5 days started as early as 30 days after the initial course of therapy. This second course may be repeated one more time.
Because establishing fertility is an ever changing field of study, encourage couples seen for subfertility who couldn't conceive but are still interested in having a child to contact their subfertility setting every
6 to 12 months to inquire about new discoveries in the field and if any of these might apply to their situation.
on average, if couples have sex 4 times a week
65% to 75% of couples will conceive within 6 months; and 90% within 12 months These periods will be longer if sexual relations are less frequent
why might progesterone be prescribed to a woman receiving IVF?
A lack of progesterone can occur if the corpus luteum was injured by the aspiration of the follicle. Therefore, 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.
NU care to empower a family (2) The following are time-honored suggestions to help aid conception:
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.
ovulation without conception graph
A woman's temperature dips slightly at midpoint in the menstrual cycle and then rises sharply, which is an indication of ovulation. Toward the end of the cycle (the 24th day), her temperature begins to decline, indicating progesterone levels are falling and she did not conceive.
ovulation with conception graph
A woman's temperature rises at the midpoint in the cycle and remains at that elevated level past the time of her normal menstrual flow, suggesting pregnancy has occurred.
congenital abnormalities why sperm count might be lowered variocele/varicosity
Abnormalities may include cryptorchidism (undescended testes) if surgical repair was not completed until after puberty or if the spermatic cord became twisted after the surgery. A varicocele, or varicosity (enlargement) of the internal spermatic vein, can also increase temperature and congestion within the testes, which may slow and disrupt spermatogenesis. Although more research is needed to determine whether a varicocele does increase temperature, surgical removal of the varicocele (varicocelectomy) may decrease warmth and improve fertility in some men
tips for ensuring an accurate semen analysis
Abstain from intercourse or masturbation for about 3 days. Use a clean, dry plastic or glass container with a secure lid to collect the sample. Collect the specimen as close as possible to your usual time of sexual activity. Avoid using any lubricants before you collect the specimen. After you've collected the specimen in the container, close it securely and write down the time you collected it. Take the specimen to the laboratory or healthcare provider's office immediately so it can be analyzed within 1 hour of collection. Keep the specimen at body temperature while transporting it. Carrying it next to your chest is one way to do this.
jobs that allow higher or lower sperm counts
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 hot tubs or saunas might also lower sperm counts often also obesity, maintain 18.5 to 24.9 Excessive weight may alter testosterone production and sperm production
advanced testing for men
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); and follicle-stimulating hormone (FSH), luteinizing hormone (LH), and testosterone levels
uterine endometrial biopsy may be used to reveal an endometrial problem like...if biopsy resembles a what then what?
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.
woman causes subfertility
ovulatory failure tubal, vaginal, cervical or utrine problems other times a couple doesn't know why they cant get pregnant "unexplained sub fertility" 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.
sub fertility said to exist
pregnancy has not occur after at least 1 year of engaging in sex unprotected
spontaneous miscarriages
same rate as natural births
infection of vagina can cause pH of vaginal secretions to become
acidotic limiting or destroying the mobility of sperm Some women appear to have sperm-immobilizing or sperm-agglutinating antibodies in their blood plasma, which act to destroy sperm cells in the vagina or cervix. Either of these immune-based problems can limit the ability of sperm to survive in the vagina and enter the uterus.
to detect day of ovulation
BBT charting mucus analysis urinary test kits for LH
least costly way to determine ovulation pattern
BBT for 4 months temp each morning before getting out of bed or any activity, eating or drinking, and using a special BBT or tympanic thermometer. She plots this daily temperature on a monthly graph while noting any conditions that might affect her temperature, such as an infection or sleeplessness. At the time of ovulation, 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).
nutrition in fertility
BMI of 18.5 to 24.9. Eating slowly digested carbohydrate foods (e.g., brown rice, pasta, dark bread, beans) and fiber-rich vegetables (e.g., asparagus, broccoli) 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
sub fertility
Because most couples have the potential to conceive but are just less able to conceive without additional help, the term subfertility is more often used today.
to assess the 3 questions of basic fertility, only 3 tests are commonly used what do nurses do for the patients here?
semen analysis in men and ovulation monitoring and tubal potency in women Nurses play key roles in preparing couples for these tests, helping them schedule the studies appropriately, and supporting them while they wait for results
what outside factors may contribute to poor ovarian function glucose/insulin? what happens when too high? what also may be instrumental in maintaining pituitary levels?
Chronic or excessive exposure to X-rays or radioactive substances, general ill health, poor diet, and stress may all contribute to poor ovarian function Nutrition, body weight, and exercise are all important for adequate ova production because they all influence the blood glucose/insulin balance When either glucose or insulin levels are too high, they can disrupt the production of FSH and LH, leading to ovulation failure. Vitamin D may also be instrumental in maintaining pituitary hormone levels
too frequent sex
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. √
NU care to empower a family (1) 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.
factors that most commonly lead to male subfertility
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
If a disturbance in ovulation is identified as the subfertility concern, administration of
GnRH (this will stimulate the pituitary to secrete more FSH and LH). therapy with Clomiphene citrate or letrozole (femur) may also be used to stimulate ovulation In other women, ovarian follicular growth can be stimulated by the administration of combinations of FSH and LH in conjunction with administration of human chorionic gonadotropin (hCG) to produce ovulation.
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
Down syndrome and hemophilia
nurses play key roles on fertility teams to help reach this goal such as...
Educating couples about the variety of tests and procedures that may be performed Helping patients identify and express their feelings about their desire to have a child Helping patients express how far they are willing to go in testing and procedures to achieve a child or how they might feel if, at the end of testing, it is revealed pregnancy will not be possible Assuming responsibility for health assessment, patient education, and counseling Helping educate couples about advanced techniques of assisted reproduction, many of which are complex and demand knowledgeable, ongoing involvement from the couple Counseling patients about available alternatives when pregnancy cannot be achieved, such as adoption or child-free living
more common reasons for subfertility
Endometriosis and poor secretion of estrogen or progesterone are more common uterine reasons for subfertility as these result in inadequate endometrial formation (overproduction or underproduction), which then interferes with implantation and embryo growth.
NU interventions clomiphene citrate
Ensure women have had a pelvic examination and baseline hormonal studies before therapy. Review medication scheduling. Urge women to use a calendar or some other system to mark their treatment schedule and also to determine and plot ovulation. Remind patients that timing intercourse with ovulation is important for achieving pregnancy. Advise patients 24-hour urine samples may be periodically necessary. Caution patients to report any bloating, stomach pain, blurred vision, unusual bleeding, bruising, or visual changes. Inform patients that therapy can be repeated for a total of three courses; if no results are obtained, therapy will be discontinued at that point.
exercise fertility
Exercising 30 minutes per day by walking or doing mild aerobics also helps to regulate blood glucose levels and increase fertility, complementing healthy eating habits
several test kits can also be found online that test for _______ and _______
FSH on third day of menstrual cycle and sperm motility for male (woman result in 30 mins, males in 10)
NU dx
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 dysfunction related to command performance of subfertility therapy" might be applicable.
When a couple first begins fertility counseling, they usually have fears and anxieties not only about their ability to conceive but also about what an identified problem will mean to their future lifestyle and family. Without information about the cause of their subfertility, each may blame the other or carry unexpressed anger toward his or her partner. Some couples may strongly desire a child but feel anxious about impending parenthood, which would bring with it a loss of independence.
For all these reasons, subfertility screening and counseling can be both an emotionally difficult and a physically demanding process, often creating a high level of strain on a couple's relationship, especially if they don't maintain open communication
________is such a priority in health care that a 2020 National Health Goal aimed at reducing subfertility was established
Having healthy children when they are wanted
health hx questions for women
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
health hx questions asked by nurse for men
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
basic fertility testing geared towards 3 questions
Is there sperm of good quality and number available? Are ova (eggs) available (i.e., woman is ovulating)? Is it possible for the sperm and egg to meet in a receptive environment?
what does GIFT require
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.
surrogates for
LGBT subfertile couples same people for adoption too
analysis of pituitary hormones. a blood test and analysis can determine whether adequate levels of...
LH and FSH are present When a man has typical male features (such as facial hair growth, laryngeal prominence, and a deeper voice), limited sperm count is rarely a problem.
what helps reduce scrotal heat and increase sperm 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.
factors that cause subfertility in women are analogous (comparable) 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
anovulation
MOST COMMON CAUSE OF SUBFERTILITY IN WOMEN absence of ovulation or release of ova from the ovary genetic abnormality like Turner syndrome (hypogonadism) in which there is limited ovarian tissue available to produce ova more often though it is a hormonal imbalance caused by conditions like 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.
Most couples assume subfertility is the woman's problem.
Many women, even after a careful explanation that the problem is their male partner's and not theirs, continue to show low self-esteem, as if the fault did rest with them.
x rays men what kind of shield
Men who are exposed to radioactive substances in their work environment should be provided with adequate protection of the testes. When you are assisting with pelvic X-rays, be certain men and boys are furnished a protective lead shield to guard against radiation to the testes.
other conditions that may inhibit sperm to testes which endocrine imbalances?
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
Referral for women over 35 years is recommended sooner because...
Referral is recommended sooner because assisted reproductive strategies such as IVF, as well as common alternatives to natural childbearing such as adoption, are also limited by age. It would be doubly unfortunate if a couple delayed fertility testing so long they not only learned they could not conceive but also were considered to be "too old" to be prospective parents by alternative methods.
semen specimens should be kept at what temperature during transportation... patients can be advised to do what?
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.
what factors contribute to determining when they should be referred for fertility evaluation
The age of a couple and the degree of apprehension they feel about possible subfertility can make a difference Although some healthcare plans or specific settings set limits on the age range in which fertility testing can be scheduled, such as not before age 18 years and not after age 45 years, other settings do not establish such limits, allowing couples of any age to benefit from assessment.
semen analysis steps
The patient is instructed to be sexually abstinent 2 to 4 days prior to the analysis. The patient ejaculates by masturbation into a clean, dry specimen jar or a special condom (one without spermicide). The number of sperm in the specimen are counted and then examined under a microscope within 1 hour of ejaculation (Box 7.5).
expected outcome evaluation
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.
ovarian hyperstimulation syndrome of IVF
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
minimum sperm count considered normal has... per ml? per ejactulation? how many percent are mobile? how many percent are normal in shape and form?
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
primary and secondary ejaculation
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. Premature ejaculation (ejaculation before penetration) is another factor that may interfere with the proper deposition of sperm. It is another problem often attributed to psychological causes. Adolescents may experience it until they become more experienced in sexual techniques.
hysteroscopy helpful to look at and further evaluate
This is helpful to further evaluate uterine adhesions, malformations, or other abnormalities such as fibroid tumors or polyps that were discovered on sonogram imaging.
can couples participating in intrauterine transfer and alternative insemination can have the sex of their kids predetermined???
True! Such techniques can be useful because popular methods to influence the sex of a child (such as douching with a baking soda mixture before coitus to have a boy or with a vinegar solution to have a girl) are more folklore than fact Allowing couples to choose the sex of children has ethical concerns because it could result in skewed male/female ratios if used by a majority of couples.
tubal patency in transvaginal hydrolaparoscopy
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
POS 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)
women physical assessment
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 (see Chapter 33 for a discussion of Tanner stages). A complete pelvic examination, including a Pap test (see Chapter 11), is needed to rule out anatomic disorders and infection.
laparoscopy part 2
a contrast medium can be injected into the uterus through a polyethylene cannula placed in the cervix to assess tubal patency (if tubes are patent, the dye will appear in the abdominal cavity). A scope may be passed directly into a fallopian tube to reveal information about the presence and condition of the fimbria and the tubal lining. If fimbria have been destroyed by PID, the chance for a normal conception is in doubt because ova seem to be unable to enter a tube if fimbrial currents are absent.
advanced testing for women increased prolactin levels means...
a rubella titer; a serologic test for syphilis; an HIV evaluation; a thyroid uptake determination; and assays for FSH, estrogen, LH, and serial progesterone levels. If a woman has a history of galactorrhea (breast milk secretions), a serum prolactin level will be obtained, as increased prolactin levels reduce the secretion of pituitary hormones. A pelvic sonogram may be performed to rule out ovarian, tubal, or uterine structural disorders.
complete tubal obstruction is the chief problem is
a woman had tubal ligation in years passed but not wants to become pregnant
To prepare for alternative insemination...on the day of 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
adverse effects clomiphene citrate
abdominal discomfort, distention, bloating, nausea, vomiting, breast tenderness, vasomotor flushing, ovarian enlargement, ovarian overstimulation, multiple births, and visual disturbances
FSH on third day of menstrual cycle...
abnormally high level is an indicator ovaries are not responding well to ovulation
when do endometriosis symptoms begin?
adolescence, with the most common sites of endometrium spread to the fallopian tubes, the cul-de-sac of Douglas, the ovaries, the uterine ligaments, and the outer surface of the uterus and bowel Some evidence of endometriosis occurs in as many as 50% of women, usually from reflux through the fallopian tubes at the time of menstruation. If viable particles of endometrium, which enter a tube this way, begin to proliferate, 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.
when may semen analysis may need to be repeated...what if man has vas deferent obstruction
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.
women in late 30s
age is related to subfertility women who defer pregnancy until this point more difficult conceiving 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.
measures to induce fertility.
aimed at improving sperm number and transport, decreasing infections, stimulating ovulation, improving nutrition, and regulating hormones
asking about alternative therapies
also important because a couple who wants to have a child could be simultaneously investigating nontraditional methods that they have heard will aid in conception Asking about herbs they may be using can reveal use of an herb that could be causing subfertility or one that would interfere with any procedure or medication prescribed for them after their subfertility investigation is complete.
allergic reaction sonohysterosalpinogram
although unlikely, an allergic reaction to the contrast medium or embolism from the medium entering a uterine blood vessel could also occur.
where are most fertility assessments conducted
ambultory settings
decreased body weight under 10% affects fertility
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)
If ovulation, sperm production, or sperm mobility problems cannot be corrected,
assisted reproductive strategies are the next step
a few men that have vasectomies develop
autoimmune reaction or form antibodies that immobilize their own sperm after the procedure also may experience long term pain unless procedure is reversed It is conceivable that men with obstruction in the vas deferens from other causes, such as scarring after an infection, could also develop an autoimmune reaction that immobilizes sperm the same way.
conception through alternative insemination takes how long to achieve?
average of 6 months 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.
If the couple is extremely apprehensive or knows of a specific problem that could be causing their difficulty in conceiving, studies should never...
be delayed, regardless of the couple's age
Transvaginal hydrolaparoscopy
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. tjen 200 ml NS to move bowel away from uterus so posterior wall of uterus, ovaries and Fallopian tubes can be assessed
peyroine disease
bent penis
if increased prolactin levels
bromocriptine is added to the med regimen to reduce prolactin levels and allow for the rise of pituitary gonadotropins
men with sperm and chemo or radiation
can be cryopreserved (frozen) in a sperm bank before radiation or chemo and then used for alternative insemination afterwards
donor ovum
can be used for woman who does not ovulate or has sex linked disease she doesn't want to pass on Young women who had extensive ovarian radiation or ovaries removed before surgery for ovarian cancer can have oocytes cryopreserved before surgery and used for IVF
sperm can either be entered into
cervix or uterus
what advised before sonohysterosalpinogram
chlamydia screen because small risk of infection
Administration of either ___ or )_____ may cause overstimulation of an ovary, causing multiple ova to come to maturity and possibly resulting in multiple births!
clomiphene citrate or gonadotropins
hydrocele
collection of fluid in tunica vaginalis of scrotum
dip stick urine test
commercial kits available for assessing upsurge of LH that occurs just before ovulation and can be used in place of BBT monitoring A woman dips a test strip into a midmorning urine specimen and then compares it with the kit instructions for a color change.
if problem of subfertility appears to be luteal phase defect...
corrected by progesterone vaginal suppositories on 3rd day of woman temp rise and continued for next 6 weeks (if pregnancy begins) or until menstrual flow begins
alternative insemination
depositing sperm into a woman cervix or uterus
when is PID most apt to occur?
end of 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.
variocele
enlargement of testicular vein
when PID left unrecognized and untreated...enters what?
enters. chronic phase which causes the scarring that can lead to stricture of Fallopian tubes and resulting fertility problems,
Clomiphene citrate
estrogen agonist to stimulate ovary binds to estrogen receptors, decreasing number of available estrogen receptors which falsely signals the hypothalamus to increase FSH and LH, THIS results in ovulation
egg freezing dilemma
ethical and religious dilemmas as to who should "own" them if the couple should divorce or disagree about their disposal at. later date
POS determined by ...what is analyzed?
examining menstrual hx but even if a woman is having her period regularly it does not mean she is also ovulating on a regular basis Fasting-glucose, testosterone, and estrogen levels are analyzed. A pelvic sonogram can be used to confirm cysts are present on the ovaries and may be the cause of subfertility
basic subfertility assessment procedures consist of
health hx physical exam lab tests to document general health specific tests for semen, ovulation, tubal patency, and uterine environment
anovulatory cycle graph
here is no preovulatory dip, and no rise of temperature anywhere during the cycle. This is the typical pattern of a woman who does not ovulate.
therapy for sperm transport disorders
if sperm not able to pass through vas deferent because of obstruction... -surgery is extensive costly and may not have a good outcome so better solution can be -extracting sperm from a point above blockage and injecting it into the vagina or uterus of the mans partner by IUI (intrauterine insemination) 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.
erectile dysfunction
impotence cant achieve erection 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
infertility
inability to conceive a child or sustain a pregnancy to birth. A couple is said to be infertile if they have not become pregnant after at least 1 year of unprotected sex.
metabolic syndrome r/t
increased cardiac disease, so efforts to reduce weight and lower triglycerides and cholesterol can improve heart health as well.
PID
infection of pelvic organs: uterus, Fallopian tubes, ovaries, supporting structures The initial source of the infection is usually a sexually transmitted disease such as chlamydia or gonorrhea. (1/4 of women) about 12% of women who acquire PID will be left sub fertile because of tubal scarring
with the use of 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.
The recovery rate for harvesting ripened eggs is high (about 90%), as is the ability to fertilize eggs by sperm in vitro. However, the overall live birth rate by IVF
is as low as 41% to 43% per treatment cycle for women under 35 years; it is as low as 13% to 18% for woman age 40 years
although a SMALL amount of contrast medium used for tubal patency...(sonohysterosalpinogram)
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.
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 5-10 of her cycle conjugated estrogen (Premarin)
if sperm present but total count is low...
man may be advised to avoid sex for 7-10 days at a time to increase the count
administration of corticosteroids to a woman effects sperm..?
may have some effect in decreasing sperm immobilization because it reduces her immune response and antibody production
stress in fertility
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.
endometriosis tx
medically or surgically
for impregnantion to take place, sperm mist be...
mobile enough to navigate the vagina, uterus, and a fallopian tube to reach the ova.
sub fertility in who
more likely woman than man cause of subfertility usually multifactoral
if FSh used to stimulate follicle growth, caution women chance for
multiple birth twins or triplets increases
higher chance of PID in women who have
multiple sex partners
if myopia or intrauterine adhesions found to be interfering with fertility....tx?
myomectomy. if growth is small can be done by hysterocopic 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. Difficult to accept because an IUD is exactly what she does not want to do (explain to her its purpose and that you can remove it after a month)
most FREQUENT CAUSE FOR ANOVULATION
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
primary subfertility
no previous conceptions
FSH test for woman 3rd day of period, educate that
not a test of her time of ovulation but a test whether she has enough FSH to stimulate egg growth!!! therefore she shouldn't use the test midpoint of menstrual cycle!!!
health insurance covers subinfertility
not always 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.
why may sperm penetration studies be necessary?
not common but may be scheduled to determine whether a mans sperm,. once they reach the ovum, can penetrate it effectively
why is IVF used
obstructed or damaged fallopian tubes or oligospermia also absence of cervical mucus prevents sperm from entering the cervix or antiserum antibodies cause immobilization of sperm
IVF procedure
one or more oocytes removed from ovary by laparoscopy and fertilized by sperm in a lab about 40 hours after fertilization, lab grown ova (now zygotes) inserted into uterus where ideally one of them will grow
In the past, multiple eggs were chosen and implanted to ensure a pregnancy resulted, but this technique also resulted in many multiple births. Because newborns from multiple births have a much smaller chance of surviving the neonatal period than others, today if a woman is under 35 years of age,
only one or two fertilized eggs are chosen and transferred back to her uterine cavity through the cervix by means of a thin catheter. In women age 40 years, up to five embryos may be transferred
suggest a couple combines involvement with fertility with other activities like...
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. It also may help provide them with time for sharing experiences and increasing intimacy, helping to compensate for any decreased enjoyment that comes from "scheduled" sexual relations.
surrogate embryo transfer for women who dont have or cant produce
ova 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.
Gamete intrafallopian transfer (GIFT)
ova are obtained from ovaries exactly as in IVF. Instead of waiting for fertilization to occur in the laboratory, however, 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.
POS
ovaries produce excess testosterone which lower FSH and LH levels which then cause irregular and unpredictable menstrual cycles
how can BPH affect semen transport
pressure from the enlarged gland on the vas deferent
secondary subfertility
previous viable pregnancy but the couple is unable to conceive at present
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.
Endometriosis
refers to the implantation of uterine endometrium, or nodules, that have spread from the interior of the uterus to locations outside the uterus 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.
what tests to determine whether adequate sperm are present for conception
semen anlysis sperm motility
proof a zygote has implanted can be demonstrated by
routine serum pregnancy as early as 11 days after transfer
difficulty with tubal transport usually 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.
If a sonogram reveals that a multiple pregnancy of more than two zygotes has been achieved, what may be recommended? how?
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
sub fertility can interfere with a persons
self concept self esteem and lifestyle
sub fertility is usually only limited to 3 assessments
semen analysis ovulation monitoring 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. talk with both of them together and each individually
fastest way to see if ovulation is occurring is to measure the womans
serum progesterone level during luteal phase of menstrual cycle (about day 21-28 day of cycle) if this is elevated it means a corpus luteum has formed or ovulation has occurred
endometrial biopsy are being performed less than once were being replaced with...
serum progesterone level evaluations that are simpler and also suggest ovulation has occurred
ejaculation concerns ID by
sexual history
Zygote intrafallopian transfer ZIFT
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.
hysterosalpingogram
similar to a sonohysterosalpingogram except a radiopaque contrast medium is used and the fallopian tubes are revealed by X-ray. uses more contrast medium so the force of the injected solution may actually break up the 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.
tests to determine if a uterine concern is leading to subfertility include
sonogram or hysteroscopy to view structure of uterus, blood work to analyze for hormones, and perhaps an endometrial biopsy
spermatozoa must be produced and maintained at a temperature... what conditions can significantly increase body temperature and potentially lower sperm count
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.`
oocyte removal who does it
sometimes NPs
sonohysterosalpinogram
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 If the tubes are patent, they will fill with the contrast medium and be detailed on the ultrasound screen. contraindicated if infection of vagina cervix or uterus present usually scheduled just following a menstrual flow when a woman could not be pregnant
erectile dysfunction can be a difficult problem to solve if related to
stress because it is not easy to get rid of
disadvantage of frozen sperm
tends to have slower motility however, appears no increase in incidence of congenital anomalies in children conceived by this method, and sperm remain viable even after years of storage
why should a woman telephone healthcare agency when she has her next menstrual flow after uterine endometrial biopsy?
this helps "date" the endometrium and the accuracy of the analysis.
infection of prostate affects composition of seminal fluid enough to reduce sperm motility how
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.
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
surrogate may provide what?
the ova which is then impregnanted by mans sperm in lab 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.
therapy for lack of tubal patency: if subfertility problem is ID as tubal insufficiency from inflammation...
the prescription of diathermy or steroid administration may be helpful to reduce adhesions
In some men, adequate sperm are manufactured, but there is obstruction at some point along the pathway spermatozoa must travel to reach the outside: what diseases?
the seminiferous tubules, the epididymis, the vas deferens, the ejaculatory duct, or the urethra 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
cervical mucus at time of ovulation
thin watery and can be easily penetrated by spermatozoa for a period of 12-72 hrs 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.
laparoscopy
trendelenburg Co2 to bring ab wall outward and better visualization might feel shoulder pain from CO2 FOLLICULAR PHASE (between first day and end of ovulation period) thin, hollow, lighted tube (a fiber optic telescope or laparoscope) through a small incision in the abdomen, just under umbilicus to examine position and state of Fallopian tubes and ovaries allows an examiner to view whether the ovaries are close enough to the fallopian tubes to allow an ovum to enter rarely done unless the results of a uterosalpingography are abnormal because it involves general anesthesia which is needed because of pain from extensive maneuvering
caution women who are prescribed Metronidazole (Flagyl) for a...
trichomoniasis infection dont use if pregnant!
Leiomas
tumors such as fibromas may be a rare cause of subfertility if they block the entrance of Fallopian tubes into the uterus or limit the space available on the uterine wall for effective implantation
testing for tubal patency
ultrasound or x ray imaging direct visualization by hysteroscope of Fallopian tubes
sterility
unable to conceive because of a known condition like the absence of a uterus
cryptorchidism
undescended testes
IVF
union of sperm and ovum under lab conditions
epispadias
urethral opening on dorsal surface
hypospadias
urethral opening on ventral surface
before beginning assisted reproductive procedures urge woman to be...she probably will also have...
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.
Hysteroscopy
visual inspection of uterus through insertion of a hysteroscops (thin hollow tube) throughh vagine, cervix, and into uterus. Women are screened for chlamydia before the examination to avoid introduction of bacteria into the uterus.
when are sperm transport disorders suspected?
when LH and FSH, which stimulate production of sperm are adequate but the sperm count remains limited
physical assessment male
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.
alternative insemination procedure
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 drugs given to induce ova maturation, many oocytes ripen at once and perhaps as many as 3-12 can be removed oocytes incubated for 8 hours 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.
Once a pregnancy has been successfully established, a woman's prenatal care is the same as for any pregnancy, although the pregnancy may be categorized as high risk because
women who have IVF procedures tend to be older than average, may be obese, and may have accompanying uterine concerns
sperm need to cross
zona pellucida zona drilling injecting sperm directly under this zone like intracytoplasmic sperm injection
