Infertility

Defining Infertility

The inability to conceive after 1 year of unprotected regular sexual intercourse (ASRM, 2003) Any involuntary inability to conceive at the time desired and includes couples who have conceived, but repeatedly lose a pregnancy before the fetus is old enough to survive Primary vs Secondary Infertility

Scope of Problem
10-20 percent of US couples cannot have a baby when they desire Infertility affects both men and women of every racial, religious, ethnic ,and socioeconomic group One out of seven couples has trouble conceiving (ASRM, 2003).

Factors contributing to infertility

Factors Contributing to Infertility Factors in a Man

Abnormalities of sperm

Abnormal hormonal stimulations of sperm production Acute or chronic illness Infections of the genital tract Anatomical abnormalities Exposure to toxins Excessive alcohol intake, illicit drugs Elevated scrotal temperature Immunologic factors produced by man against his own sperm or by the woman causing the sperm to clump

Factors Contributing to Infertility Factors in a Man (cont)

Abnormal erections
Physical

and psychological factors

Abnormal ejaculation
Retrograde

ejaculation Anatomic abnormalities Premature ejaculation

Abnormalities of seminal fluid

Effect of Smoking on Fertility

In one study, it was shown that the average percentage of sperm penetration was significantly lower in smokers in comparison with non-smokers. These observations suggest that smoking is a risk factor for reduced fertility.(Cigarettes, alcohol
and marijuana are related to pyospermia in infertile men. The Journal of Urology 1990; 144(4):900903)

Female causes of infertility

Factors Contributing to Infertility Factors in a Woman

Disorders of ovulation
Dysfunction

in the hypothalamus or pituitary gland that alters secretions of GnRH, FSH and LH Failure of ovaries to respond to FSH and LH

Abnormalities of Fallopian Tubes

Tubal

obstruction Congenital abnormalities

Abnormalities of the Cervix

Obstructed

cervix Abnormal cervical mucus

Factors Contributing to Infertility The Age Factor

Societal trend for women to delay childbirth (college or career constraints) Fertility declines with age
Fewer

eggs remain in the ovaries Quality of eggs is lower Lower response to fertility medications Increased chance for chromosomally deformed embryo

Ideal age to have children 18-28

Repeated Pregnancy Loss

Repeated Pregnancy loss

Abnormalities of the Fetal Chromosomes Abnormalities of Cervix or Uterus Endocrine Abnormalities Immunologic Factors Environmental Agents Infections

Evaluation of infertility

Detailed History

Pattern of intercourse in relation to womans cycles and length of time couple has had unprotected intercourse GYN history Previous pregnancies and their outcomes, fertility with other partners. Previous surgeries, infections, serious illness and injury Exposure to toxins and prescribed medications Family history of multiple pregnancy losses or birth defects Knowledge of male and female anatomy/reproduction

Evaluation of infertility

Physical exam
Full

physical with emphasis on reproductive organs for structural defects, infection, cysts or other abnormalities Pap smear/vaginal cultures Check for s/sx of endocrine disturbances Cranial tumors Undiagnosed chronic disease

Evaluation of Infertility Less Invasive

Diagnostic tests
Semen analysis Performed within one hour after ejaculation Measures volume of ejaculate, #/quality of sperm

Basal

Body Temperature/ovulation predictor kits Postcoital test

Evaluates the ability of sperm to survive the cervical mucus 12 to 24 hours after intercourse at ovulation
Endocrine

Tests Ultrasound evaluate a womans anatomy

Evaulation of Infertility More invasive

Hysterosalpingogram Introduction of radiopaque dye into uterine cavity to view anatomical structures under x-ray; may also be therapeutic
Hysteroscopy Fiberoptic instrument used to provide direct visualization of uterine cavity Endometrial biopsy Evaluates the effects of progesterone on uterine lining Laparoscopy Direct visualization of outside the uterus and tubes under general anesthesia to diagnose and treat endometriosis

Therapies-- Medications

Therapies-- Medications

Bromocriptine (Parlodel)

Corrects excess prolactin levels Increases ovulation and supports early pregnancy by stimulating progesterone secretion by the corpus luteum Stimulate ovulation in the female or sperm formation in the male Induction of ovulation in women by GnRH secretion Stimulates ovarian follicle growth

Chorionic gonadotropins (Pregnyl)

Clomiphene citrate (Clomid)

FSH (Gonal-F)

Therapies-- Medications

GnRH antagonist (Cetrotide, Anatagon)

reduces endometriosis.

GnRH agonist (Zoladex, Lupron, Synarel)

Stimulates release of FSH and LH from the pituitary gland in men and women.

Therapies-- Medications

Gonadotropins (Perganol)

Induction of ovulation with FSH and LH

Progesterone (IM prep or vaginal suppositories)

Luteal phase support, prepares uterine lining and promotes implantation of embryo

Erectile agents (Viagra, Levitra)

Increases blood flow to the penis, improving erectile function.

Therapies Surgical Procedures

Therapies Surgical Procedures

Endoscopic procedures - to correct obstructions with minimal

invasiveness.

Laparatomy to relive pelvic adhesions and obstructions caused

by endometriosis, infections or previous surgical procedures.

Laser surgical techniques to reduce adhesions; minimally

invasive, precise and less likely to form new adhesions.
Correction of a varicocele by ligating or embolizing the dilated veins may improve sperm quality and quantity.

Transcervical balloon tuboplasty to unblock the fallopian

tubes.

Therapies
Intrauterine

Insemination (IUI)

When infertility is due to a male factor, cervical mucus problem, or for donated sperm Sperm (partner or donor) is washed and concentrated and injected directly into the uterus

Egg

Donation

Surrogate

parenting

Therapies
Advanced Reproductive Techniques

IVF --- in vitro fertilization

to

bypass the fallopian tubes when infertility os due to a male factor, blocked tubes, or unexplained infertility Process:

Starts with ovulation induction Oocytes are retreived transvaginally Sperm are combined with the eggs in the laboratory and after fertilization, normal developing embryos are transferred into uterus (2 to 5 days later)

GIFT --- gamete intrafallopian transfer ZIFT --- zygote intrafallopian transfer

IVF

Embryo Transfer

IVF Success Rates

Cost issues --- Insurance

Five states require the offer of coverage (California, Connecticut, Ohio, Texas, and West Virginia). Nine states mandate coverage for infertility treatment (Arkansas, Hawaii, Illinois, Maryland, Massachusetts, Montana, New Jersey, New York, and Rhode Island). The services and treatments these states require vary considerably, as does the definition of infertility. Only two states permit lifetime benefit maximums: Arkansas (not less than $ 15,000) and Maryland (not to exceed $ 100,000).

Cost issues --- Insurance

Illinois has mandated coverage of infertility

Companies have > 25 employees Must include coverage for the diagnosis and treatment of infertility, including IVF, uterine embryo lavage, embryo transfer, artificial insemination, GIFT, ZIFT. Coverage for IVF, GIFT, or ZIFT is required only if the patient has been unable to attain or sustain a successful pregnancy through reasonable, less costly, medically-appropriate infertility The infertility coverage need not be included in a policy issued to or by a religious institution that finds the procedures to violate its religious and moral teachings and beliefs

Cost Issues

Cost Issues

Example

The expected cost of IVF is $9,000. This covers office visits, injection training, estrogen and ultrasound monitoring, hospital retrieval costs, 6 months of embryo freezing, lab fertilization expenses, hospital transfer costs and physician services for each cycle None of these costs include medication.

A major cost of each cycle is medication. The range of medication costs is between $1,500 and $4,000 per cycle, with an average cost about $2,700. Costs can vary tremendously, even for the same medication.

Emotional issues in infertility

Emotional Issues in Infertility

Studies show that women experiencing infertility have the same depression and anxiety levels as women experiencing life-threatening illness like cancer of heart disease (Burns & Covington, 1999). Infertility therapy is a major commitment - of time, expense, money, and exposes a persons emotions, insecurities, and sexual (dys)functions Can cause relationship strain

Emotional Issues in Infertility

Shock Denial Guilt Anger Depression Isolation Loss of control Hopelessness

Emotional Issues in Infertility

Easily recognizable signs that might indicate an infertility patient having psychological issues:
Difficulty

or delay in decision making Not following directed care Obvious emotional distress at visits Differences of opinion with spouse Multiple phone calls Missed appointments Inappropriate behavior to staff

Emotional Issues Role of the Nurse

Listen for negative remarks as well Normalize emotional reactions Note how the process is affecting a couples relationship Ask about religious/cultural views Anticipatory guidance Coping strategies Provide privacy and an environment of acceptance Treat the couple but address individual needs Give back control/help explore options Refer as indicated

Ethical Issues in Infertility

Ethical Issues

Multiple gestation Prevention

using the least potent drugs in the lowest effective doses Limiting number of fertilized embryos (ACOG recommendations no more then three) ACOG recommends counseling patients about the risks of multiple pregnancies before treatment begins. The guidelines also state that, for some of those who are opposed to abortion, nonselective embryo reduction is ethically justified, since the intent is to deliver a healthy child

Multi-fetal pregnancy reduction

Only available to higher socioeconomic population? Egg donation

Selling children? What to do with frozen fertilized eggs?

Role of the nurse in infertility

Manager Educator Counselor Researcher Professional Practitioner

References

Burns, L. H. & Covington, S. N. (Eds.). (1999). Infertility counseling a comprehensive handbook for clinicians. New York: The Parthenon Publishing Company. American Society for Reproductive Medicine (1997). Unexplained Infertility: a guide for patients. Birmingham: American Society for Reproductive Medicine. American Society for Reproductive Medicine (1995). Infertility: Coping and Decision making: a guide for patients. Birmingham: American Society for Reproductive Medicine. Morris, E. J. (2001) The role of infertility nurses in ovulation induction programmes. Human Fertility 4(1), 14-7.