Women's Fertility Drugs
overview of fertility drugs
There are numerous causes of infertility in women and men. Female factors that can result in infertility include genetic, tubal or peritoneal, ovarian, cervical, uterine, endocrine, and age-related factors, as well as drug use, excessive alcohol intake, tobacco use, and malnutrition. Factors related to couples that can result in infertility include intercourse frequency, intercourse timing, sexual technique, and immune response to sperm. Male factors that can result in infertility include genetic, seminal, transport, testicular, endocrine, and age-related factors, as well as drug use, excessive alcohol intake, exposure to pollution, tobacco use, scrotal heat exposure, infectious processes, malnutrition, allergies, and autoimmunity to sperm. The wide variety of medical treatments used for infertility fall into the category of assisted reproductive technology (ART). Drugs that promote follicular maturation, stimulate ovulation, and promote ovulation control are most commonly used to treat infertility. Oral drug therapy is the first line of drug treatment for ovulatory dysfunction disorders. A detailed assessment of the infertile couple guides the choice of medical treatment.
The nurse is teaching a woman how to evaluate and record her basal body temperature and explains that ovulation is predicted by which temperature change? With a 0.5 degree drop, followed by a 1 degree rise in basal body temperature With a 0.5 degree drop, followed by a 0.5 degree rise in basal body temperature With a 1 degree drop, followed by a 1 degree rise in basal body temperature With a 1 degree drop, followed by a 0.5 degree rise in basal body temperature
With a 0.5 degree drop, followed by a 1 degree rise in basal body temperature
Lucy should be instructed to take CC during which time of the menstrual cycle? CASE STUDY DETAILS At the beginning, during days 1-4 Before ovulation, during days 5-9 During ovulation, during days 10-14 After ovulation, during days 15-20
before ovulation during days 5-9
A couple is discussing how often they should have intercourse when trying to conceive. Which is the best recommendation for a couple with a male who has a lower than normal sperm count?
every other day
A couple is discussing how often they should have intercourse when trying to conceive. Which is the best recommendation for a couple with a male who has a normal sperm count?
frequently from 4 days before to 3 days after ovulation
A patient asks about clomiphene citrate for infertility and the nurse notices that she demonstrates which contraindication to taking this medication?
history of DVT
What is the first line of pharmacologic treatment for ovulatory dysfunction disorders? Induction of ovulation by oral drug therapy. Induction of ovulation by intravenous drug therapy. Induction of ovulation by vaginal suppositories. Induction of ovulation by intramuscular injection.
induction of ovulation be oral drug therapy
A patient has hyperinsulinemia and polycystic ovarian syndrome (PCOS). She is started on clomiphene citrate in combination with what other medication for a higher success rate of treatment?
metformin
A patient is discussing possible use of clomiphene citrate and is concerned that it might harm her baby if she gets pregnant. How should the nurse respond?
neural tube defects have been reported, but not confirmed by controlled studies
A patient wants to stop taking clomiphene citrate, and asks when the drug will be out of her system. Which is a correct answer?
5 days
Pre-admin assessment of patient
A complete and thorough assessment of both the patient and the couple helps the health care provider to identify possible causes of infertility and determine the best course of treatment. Assess the patient's general health history, including drug and herbal product use. Perform physical examinations, including speculum and bimanual exams. Assess the patient's reproductive and sexual histories, paying attention to any history of abnormal Pap testing and treatment, vaginal infections and/or STIs and treatment, past use of contraception methods, pelvic surgery, past and/or present gynecologic abnormalities, and pregnancy and birth complications. Take a complete menstrual history, including menarche, the last menstrual period's length, duration, and flow of bleeding, and any other signs or symptoms related to the menstrual cycle.
which are results of taking clomiphene citrate?
ovarian stimulation maturation of ovarian follicle ovulation
A woman has tried three cycles of clomiphene citrate without success. She is tearful during her appointment and admits she feels depressed when she sees a pregnant woman. Which is an appropriate intervention by the nurse?
refer the patient to a psychologist or therapist
The nurse is meeting with a woman who has not been able to conceive and is not interested in reproductive assistance because of her religious beliefs, though this causes her to feel very depressed. Which is the best intervention taken by the nurse?
support the patient's decision suggest adoption refer the patient to a psychiatrist
A patient mentions she forgot to take her "seeds" one day last week. You find out she is referring to an herbal supplement her grandmother told her to use. Which teaching point is appropriate?
tell the patient to find out the name of the herbal supplement
How is clomiphene citrate excreted? Through the feces During sexual intercourse During menstruation Through the urine
through the feces
Which is a contraindication to the use of CC? Family history of ovarian cyst Uterine fibroids Menarche prior to age 11 Age of 35 or older
uterine fibroids
The nurse should teach a patient receiving CC about which side effects? Select all that apply. Weakness Dizziness Amenorrhea Increased appetite Breast enlargement
weakness dizziness increased appetite
Dosage and Admin of CC
CC is given during days 5-9 of the menstrual cycle. CC is first administered in 50-mg/day oral dose. If ovulation does not occur, this dose can be increased by 50 mg/day for a second course of 5 days. Once a dose is established, that dose should be given for a maximum of three sequential cycles. Doses higher than 100 mg/day are not recommended. Each new regimen should begin no sooner than 30 days after the previous medication regimen. When ovulation occurs (usually within 5 to 10 days after the last CC dose), intercourse should take place at least every other day.
Therapeutic use of Clomiphene Citrate
CC is used to stimulate ovarian follicle growth.
Adverse effects of CC
CC may cause side effects, including breast tenderness, breast pain, hot flashes, uterine bleeding, blurred vision, headaches, abdominal bloating, nausea, vomiting, and visual changes. Reversible hair loss has also been noted. The effects of CC on the development of a human fetus are unclear, but developmental abnormalities have been reported in animals. Neural tube defects have been reported, but controlled studies have not confirmed this suggested finding.
pharmacodynamics of Clomiphene Citrate
Clomiphene citrate (CC) is the most commonly used ovulation stimulant. For women diagnosed with hyperinsulinemia, clomiphene is a first-line drug for ovulation induction and may be used in combination with metformin.
contraindications and drug interactions of CC
Contraindications CC is contraindicated for patients with thyroid disease, adrenal disease, liver disease, thromboembolic disease, pituitary failure, ovarian failure, uterine fibroids, undiagnosed vaginal bleeding, and depression, as well as patients who are already pregnant. Existing ovarian cysts may enlarge when CC is taken. Drug Interactions CC does not have any known significant drug interactions, and there are no known drug interactions between CC and human chorionic gonadotropin (hCG). Some actions of CC may interfere with conception during the luteal phase; this interference can be prevented by adding progesterone to a patient's medication regimen.
Pharmacokinetics of Clomiphene Citrate
Data on the pharmacokinetics of CC are limited, but the known pharmacokinetics of CC consist of the following: Half-life of 5-7 days Easily absorbed from the GI tract Metabolized in the liver Excreted in feces via biliary elimination
The nurse is meeting with a couple who is having difficulty conceiving. The male storms out of the office yelling, "This is her fault; she is broken!" The nurse understands that what may be taking place?
In a male dominated culture, infertility is viewed as a female problem.
Cultural Considerations
In male-dominated cultures, women are often blamed for infertility and/or may immediately place the blame of infertility on themselves. Conflicts between religious and/or cultural traditions and the use of reproductive technology may be an ongoing challenge that creates much stress and anxiety for couples. Support and appropriate resources should be suggested to such couples and utilized in such instances. Women may need to remain covered as much as possible during exams in order to maintain patient dignity and respect. Often patients will combine conventional medicine with traditional medicine for infertility issues. A thorough history of conventional medicine uses is necessary in order to determine appropriate treatment. If a patient has a language barrier, the appropriate interpreter is necessary. Health care providers of the same gender and/or culture may be preferred by patients dealing with sensitive issues such as infertility. Support should be provided to the patient for the physical, psychological, emotional, and spiritual aspects of infertility, and the appropriate interventions should be put in place.
Assessment of a patient with infertility should involve a complete menstrual history, including which aspects? Select all that apply. Menarche Last menstrual period Length/duration/flow of bleeding Other manifestations related to the menstrual cycle Last date of intercourse Number of pregnancies
Menarche Last menstrual period Length/duration/flow of bleeding Other manifestations related to the menstrual cycle
Side effects of CC
Patients may experience breast discomfort, fatigue, hot flashes, night sweats, depression, dizziness, nausea, heavy menses compared to baseline, abdominal bloating, and abdominal pain. In rare cases, patients may experience dermatitis, increased appetite, urticaria, weakness, and anxiety. CC may interfere with maturation of the endometrium and cervical mucus production, thereby interfering with pregnancy.
Assessment of the couple
Perform a complete assessment of the couple's sexual practices, including use of lubricants and timing and technique of intercourse. Assess the couple's mental health status and provide a referral to a support group or counseling as needed. Infertility can be isolating, because many couples experiencing infertility may have several peers who are pregnant or already have children. Prepare the couple for the exhaustive battery of diagnostic tests they will undergo to evaluate the cause of infertility. Once the cause of infertility is determined, conditions that contraindicate the treatment of choice must be ruled out. Help the couple discuss their feelings in a safe, supportive environment. It is particularly important that the couple's interpretation of their infertility be explored, along with its impact on their relationship.
The patient asks if there is anything she can do to increase her chances of conception, other than taking the prescribed medication. The nurse teaches which sexual technique?
Placing a pillow under the woman's hips during intercourse and laying supine with hips elevated on a pillow for 30 minutes after ejaculation.
Mediation specific Interventions
Review the expected outcomes of the drug regimen according to the health care provider's prescription. Teach the importance of adhering to the medication regimen to help minimize any adverse physical, psychological, emotional, and spiritual effects. Discuss the importance of contacting the health care provider if any visual disturbances or abdominal pains are experienced. Inform the patient that she will need to use caution with activities that require alertness. Instruct the patient that medication should be taken at the same time daily. This creates steady blood levels and enhances drug effectiveness. Instruct the patient to notify the health care provider if a medication dose is missed. Ensure the patient understands that there is a chance of multiple births with the use of CC and is aware of the benefits and risks for and alternatives to this medication.
interventions with CC to promote Conception
Teach patients the importance of taking their basal temperature 5 to 10 days following CC. Discuss the interconnectedness of ovulation, the menstrual cycle, and sexual intercourse as related to conception. Provide tips that enhance the chance of fertilization, include the positioning of a pillow under the women's hips during intercourse and elevation of the woman's hips for 30 minutes post intercourse. Offer psychological support and counseling. Many times multiple attempts must be made before successful conception takes place.
Evaluation for CC
The desired outcome for CC treatment in infertility is for the patient to become pregnant, resulting in the birth of an infant. If this outcome is not obtained, alternatives to childbearing should be discussed and appropriate support should be arranged to avoid adverse impact of the failed treatment on the couples' self esteem and/or harm to their relationship. The couple should be encouraged to express feelings and voice concerns about treatment success and/or failure throughout the entire experience.
Mechanism of action for Clomiphene Citrate
The mechanism of action of CC is unknown. This drug binds at estrogen receptor sites in the hypothalamus and pituitary, thereby causing in an increase in the release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH). The results of increased FSH and LH are maturation of follicles and ovulation. Women with PCOS may need concurrent treatment for hyperinsulinemia with metformin. Metformin helps regulate the menstrual cycle and promote ovulation when used singly; however, when it is paired with CC, the success rate is increased.
Patient teaching for CC
The nurse should provide teaching to the patient about how to maximize the chances for conception and how to properly use fertility drugs. The nurse should also explain to the patient which side effects can be expected and which side effects are serious and warrant contacting the provider. Changes in basal body temperature and changes in cervical mucus are indicative of ovulation status. Couples should evaluate and record day 1 of the menstrual cycle. For prime ovulation to be predicted, a 0.5° F drop in basal body temperature followed by a 1° F rise in basal body temperature is needed. Ovulatory kits can be used to help couples determine the prime time for sexual intercourse. Couples should be taught to engage in intercourse 4 days before ovulation and 3 days after ovulation. Couples should engage in intercourse every other day if low sperm count is an infertility factor. Skipping a day will help maximize sperm count. The medication should be taken at the same time daily to enhance the medicine's effects and sustain therapeutic blood levels. Couples should be encouraged to express feelings and voice concerns about treatment success and/or failure throughout treatment.
Clomiphene citrate is thought to compete with which hormone?
estrogen
A patient asks if she can take clomiphene citrate every day to increase the chances for pregnancy. How should the nurse respond?
"Take 50 mg oral dose on days 5-9 of the menstrual cycle. If not effective, the dose can be increased, but the days used are not increased."
