Infertility

INFERTILITY

  • Infertility is a significant social and medical problem affecting couples world-wide.
  • Infertility refers to an inability to conceive after having regular unprotected sex.
  • Infertility may result from an issue with either you or your partner, or a combination of factors that prevent pregnancy.
  • Some causes can be detected and treated, whereas others can not

DEFINITION OF INFERTILITY

“Infertility is the failure to achieve a birth ever a 12 months period of unprotected intercourse”

“Infertility is the inability of a sexually active non contracepting couple to achieve pregnancy in one year”

“Infertility is defined as a failure to conceive within one or more years of regular unprotected coitus”

NCIDENCE OF INFERTILITY

  • 80% of couple achieve conception if they so desire, within one year of having regular intercourse with adequate frequency (4-5 times a week)
  • Another 10 % will achieve the objective by the end of second year
  • As such, 10% remain infertile by the end of second year
  • In India, approximately 15% to 20% of couples are infertile
  • According to Mayo clinic, USA-
  1. 30% cases of infertility are due to a problem in man.
  2. 40% to 50% cases are due to women.
  3. 20% cases are due to problem in both men & women

TYPES OF INFERTILITY

 Primary infertility

  • It is defined as the absence of a live birth for women who desire a child and have been in a union for at least 12 months, during which they have not used any contraceptives.
  • The World Health Organisation also adds that 'women whose pregnancy spontaneously miscarries, or whose pregnancy results in a still born child, without ever having had a live birth would present with primarily infertility.

Secondary infertility

  • It is defined as the absence of a live birth for women who desire a child and have been in a union for at least 12 months since their last live birth, during which they did not use any contraceptives.

 Cause Male Infertility-

LOW SPERM COUNT

 • Less than 10 million sperm per ml of semen. Normal count is 20 million sperm per ml of semen or more.

NO SPERM

 • Absence of sperms in semen.

 LOW SPERM MOTILITY

• Sperms are immotile, cannot swim.

ABNORMAL SPERMS

• Unusual shape, more difficult to move and fertilize egg

CAUSES OF FEMALE INFERTILITY

• Ovarian factors: (30-40%)

  1. Anovulation or oligo ovulation
  2. Decreased ovarian reserve
  3. Luteal phase defect
  4. Luteinised unruptured follicle

• Tubal and peritoneal factors: (25-30%)

  1. Obstruction of tube due to Pelvic infections
  2. Previous tubal surgery or sterilisation
  3. Salpingitis isthmica nodosa
  4. Tubal endometritis
  5. Polyp or mucous debris within the tubal lumen

• Peritoneal factors

  1. Peri tubal adhesion and minimum endometriosis
  2. Deep dyspareunia

 Uterine factor

  1. Hypoplasia
  2. Inadequate secretory endometrium
  3. Fibroid uterus
  4. Endometritis
  5. Congenital mal formation of uterus

• Vaginal factors

  1. Atresia vagina
  2. Transverse vaginal septum
  3. Septate vagina
  4. Vaginitis or purulent discharge

Cervical factors

  1. Anatomical defects that prevent entry of the sperm like elongation of cervix, second degree uterine prolapse, and acute retroverted uterus
  2. The fault lies in the composition of the cervical mucus, so much that the spermatozoa fail to penetrate the mucus.
  3. The mucus may be scanty following amputation, deep cauterisation of the cervix
  4. The abnormal constituents include excessive, viscous or purulent discharge as in chronic cervicitis

COMBINED FACTORS

  • Presence of factors both in male and female partners causing infertility
  • Advance age of wife beyond 35
  • Infrequent intercourse, lack of knowledge of coitus technique and timing of coitus to utilize the fertile period
  • Apareunia and dyspareunia
  • Anxiety and apprehension
  • Use of lubricant during intercourse
  • Immunological factors

DIAGNOSIS OF FEMALE INFERTILITY

• History

  1. A general medical history
  2. The surgical history
  3. Menstrual history
  4. Previous obstetric history
  5. Contraceptive practice
  6. Sexual problem

• Examination

  1. General examination
  2. Systemic examination
  3. Gynaecological examination
  4. Speculum examination

DIAGNOSIS OF OVULATION

  1. Indirect
  • Menstrual history
  • Sonography/CT Scan/MRI
  • Evaluation of peripheral or end organ changes
  1. BBT
  2. Cervical mucus study
  3. Vaginal cytology
  4. Endometrial biopsy
  5. Hormone estimation
  1. Serum progesterone
  2. Serum LH
  3. Serum oestradiol
  4. Urine LH
  1. Direct
  • Laparoscopy/ Hysteroscopy/ Hysterosalpingography (HSG)
  1. Conclusive: Pregnancy

Treatment for Infertility-

COUPLE INSTRUCTIONS

  • Assurance
  • Body weight
  • Smoking and alcohol
  • Coital problem
  • To improve spermatogenesis the following measures should be useful

TREATMENT FOR MALE INFERTILITY

General care

  • Improvement of general health, reduction of weight in obese, avoidance of alcohol and heavy smoking
  • Avoidance of tight and warm undergarments or occupation that may elevate testicular temperature
  • Use of vitamin E,C,D, B12 and folic acid and antioxidant to improve spermatogenesis
  • Medication that interfere spermatogenesis should be avoided
  1. TREATMENT OF HORMONAL PROBLEMS
  • In hypogonadotrophic hypogonadism, the disorder of spermatogenesis can be treated with-
  1. hCG 500 IU intramuscularly once or twice a week is given to stimulate endogenous testosterone production
  2. hMG is added to hCG when there is no sperm in the ejaculate with hCG alone
  3. Dopamine agonist is given in hyperprolactinaemia to restore normal prolactin and testosterone level
  • If LH, FSH levels are low then it can be treated with Clomiphene citrate 25-50 mg orally daily for 25 days with rest for 5 days for 3 cycles is given. It increases serum level of FSH, LH and testosterone
  • Cortisone replacement therapy for normal functioning of pituitary
  1. TREATMENT OF PHYSICAL PROBLEM
  • Varicocele treated with microsurgery that involves the interruption of the damaged testicular veins.
  • Blocked ducts can be corrected by a reversal vasectomy which connect the testicles to the vas deferens. In case of congenital absence of vas deferens, failed reversal vasectomy, then Sperms can be extracted directly from the testicles and injected into an egg in laboratory.
  • Hydrocele is corrected by surgery
  • Epididymal blockage: A bypass of the blockage can be performed, called vasoepididymostomy (vas deferens is re-connected to epididymis).
  • Orchidopexy in undescended testes should be done between 2-3 years of age
  1. TREATMENT OF EJACULATORY DYSFUNCTION
  • In retrograde ejaculation, phenylephrine is used to improve the tone of internal urethral sphincter.
  • Electroejaculation can be used to induce ejaculation.
  • Vibration stimulation employs to induce a reflex ejaculation.
  1. TREATMENT OF ERECTILE DYSFUNCTION
  • Pharmacological treatment: For erectile dysfunction, sildenafil 25-100 mg or tadalafil 10-20 mg is currently advised. A single dose orally one hour before sexual activities should be given
  • Mechanical treatment: involves the use of vacuum erection device with a constructive ring.
  • Surgical treatment: involves the use of implant or the correction of vascular damage/blockage to restore erectile capacity.
  • Psychotherapy
  • Behaviour therapy
  • Squeeze technique to treat premature ejaculation

DRUGS FOR STIMULATION OF OVULATION

  • Clomiphene citrate
  • Letrozole
  • hMG (hum Egon, pergonal)
  • FSH
  1. Purified urinary FSH
  2. Highly purified urinary FSH
  3. Recombinant FSH

• hCG (Profasi, Pregnyl)

  1. Recombinant hCG

• GnRH

• GnRH analogue

 • Bromocriptine

Correction of biochemical abnormality

  1. Hyper insulinemic- Metformin
  2. Androgen excess- Dexamethasone
  3. Prolactin raised- Bromocriptine

• Substitution therapy

  1. Hypothyroidism-Thyroxin
  2. Diabetes mellitus- Antidiabetic drug

• Monitoring during ovulation induction

  • BBT recording

Surgery

  • Laparoscopic ovarian drilling or laser vaporisation: done by multiple punctures of the cysts in polycystic ovarian syndrome by diathermy or laser
  • Wedge resection: Bilateral wedge resection of the ovaries is done in PCOS cases where clomiphene citrate fails to induce ovulation
  • Surgery for pituitary prolactinomas
  • Surgical removal of virilising or other functioning ovarian or adrenal tumour

IMMUNOLOGICAL FACTORS

  • In the presence of ant sperm antibodies in the cervical mucus, dexamethasone 0.5 mg at bed time in the follicular phase may be given
  • In ant sperm antibody positive patient COH and IUI or IVF or ICSI is recommended

UTEROVAGINAL SURGERY

  • Myomectomy
  • Metroplasty
  • Adhesiolysis with insertion of IUCD in uterine synechiae
  • Enlargement of the vaginal introitus or removal of vaginal septum
  • Apart from cauterisation, amputation of the cervix may have to be done for congenital elongation of the cervix
  • Gilliam’s type of operation to correct third degree retroversion in unexplained infertility

UNEXPLAINED INFERTILITY

  • It is for the couples who have undergone complete basic infertility work up and in whom no abnormality has been detected and still remain infertile
  • The recommended treatment is induction of ovulation, IUI, superovulation combined with IUI and ART
  • The fault detected in both the partners should be treated simultaneously and not one after the other

INFERTILITY COUNSELING

• Infertility counselling deals with the psycho- social impact of infertility in terms of

  1. Intervention,
  2. Treatment, and
  3. After-effects of both successful and unsuccessful treatments.
  • It also involves therapeutic work to help patient cope with the consequences of infertility & treatment.

OBJECTIVES & NEED OF INFERTILITY COUNSELING

  • Informed consent.
  • To offer coping strategies to couples.
  • To facilitate decision making.
  • To offer preparation for procedures.
  • To help client in achieving a better quality of life.
  • To provide genetic counselling

ADVANTAGES OF INFERTILITY COUNSELING

  • Helps to deal with the emotional stress.
  • Provide extra support.
  • Allow the client in exploring all possible options for family.
  • Help the couples in overcoming the dilemmas & deciding the right fertility treatment.
  • Explains about the infertility management & specific treatment.

ROLE OF NURSE IN INFERTILITY COUNSELING

  • Receiving the patient & family, and make them accessible & comfortable for counselling.
  • Fertility nurse specialists provide care for the individuals and couples before, during, and after fertility treatment.
  • Nurse need to obtain history as prenatal, family and other relevant history.
  • Nurse has to perform primary physical examination and collect other relevant information regarding patient of reports.
  • Give psychological support throughout the counselling.
  • Collect other information about tests, reports & documents.
  • Establish plan of care with family and co- ordinate care with other health care professionals.
  •  Maintain privacy and confidentiality of all cases.

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