INFERTILITY

PRESENTED BY:LABIBA SUPERVISER:DR.ELHAM

INFERTILITY

Infertility is the inability to achieve

pregnancy after at least one year of

regular sexual intercourse without

contraception.

CLASIFICATION

Primary• Never conceived in the past and

who have regular, unprotected intercourse for 12 month.

Secondary• Conceived in the past and who

have regular, unprotected intercourse for 12 month.

Voluntary• Never tried for a pregnancy and

have taken contraception to avoid pregnancy.

ETIOLOGY

Female causes: Developmental: uterine abnormalities. Endocrine: ( inhibit maturation and release of ova ) pituitary, thyroid and adrenal dysfunction, ovarian dysfunction .

CON…

Diseases: PID, fallopian tube obstruction, diseases of cervix and uterus ( inhibit passage of active sperm ). Other: malnutrition, sever anemia, anxiety.

Endometriosis Occurs when the

uterine tissue implants and grows outside of the uterus, affecting the function of the ovaries, uterus and fallopian tubes.

Scar tissue can block the fallopian tubes and prevent the egg from entering the uterus.

PID Pelvic inflammatory disease (PID) is

a spectrum of infections of the female genital tract that includes endometritis, salpingitis, tuboovarian abscess, and peritonitis.

Uterine Fibroids Fibroids are

benign tumors in the wall of the uterus

May cause infertility by blocking the fallopian tubes.

Pelvic adhesions

Pelvic adhesions are bands of scar tissue that bind organs after pelvic infection, appendicitis, or abdominal or pelvic surgery.

This scar tissue formation may impair fertility.

Ovarian failure Ovarian failure can be a

consequence of medical treatments, or the complete failure of the ovaries to develop or contain eggs in the first place (Turner's Syndrome).

Ovarian failure can also occur as a result of treatments such as chemotherapy and pelvic radiotherapy for cancers in other body areas. These therapies destroy eggs in the ovary.

HORMONAL

Ovulation disorders. Elevated prolactin. Polycystic ovary syndrome. Early menopause.

Ovulation disorders

Disruption in the part of the brain that regulates ovulation can cause low levels of luteinizing hormone (LH) and follicle-stimulating hormone (FSH). Even slight irregularities in the hormone system can affect ovulation.

Elevated prolactin

Also called hyperprolactinemia. Can cause irregular or no ovulation. Irregular periods. May cause galactorrehea, milk production when not pregnant.

PCOS Polycystic ovary

syndrome (PCOS).

Produces too much androgen hormone (male hormones).

Causes an irregular or no menstrual cycle.

Early menopauseAbsence of menstruation. Early depletion of ovarian follicles before age 35. Although the cause is unknown, certain conditions are associated with early menopause, including immune system diseases, radiation or chemotherapy treatment, and smoking.

Male causes: Developmental: Undescended testes, other congenital abnormalities ( inhibit development of sperm ).Disease: Testicular destruction from disease, orchitis from mumps, prostatitis.

CON… Coital problem

Tight circumcision. Ejaculatory problem such as:

Immature ejaculation. Impotence. Epispadius & hypospadius. Retrograde ejaculation ( due to prostate operation ).

CON… Anti-sperm antibodies:

Which may found in the serum of wife or husband or in cervical mucus. Seminal problems : Volume, Count, Motility and morphology.

CON…

Other: Excessive smoking, fatigue,

alcohol, excessive heat (hot bath).

CON…

Both male and female: Diseases: STD, cancer causing obstructions (inhibit transport of ovum or sperm). Others: Immunological incompatibility (inhibit sperm penetration of ovum),marital problems.

RISK FACTORS

Increasing age.Tobacco and illicit drug use. Extremes of exercise activity. Sever dietary restriction. Specific occupational. STDs. Overweight.

CLINICAL MANIFESTATION

Clinical manifestation of the causes

of infertility.

Infertility produce profound

psychological effects.

INVESTIGATIONS

Male: Semen analysis to determine presence, number and motility of sperms. Testicular biopsy if sperm number low or absent.

CON…Female:

Basal body temperature chart to determine that the ovulation is occurring.Postcoital test of cervical secretion to measure the ability of sperm to penetrate cervical mucosa and remain active, determine quality of mucus .

CON…

Endometrial biopsy to determine whether ovulation is occurring. Laparoscopy to examine the pelvis and determine patency of fallopian tubes. Hystero-salpinogography to determine patency of uterus and fallopian tubes.

CON…

Male\ Female:

Hormonal tests to determine

whether problem is hormonal.

MANAGEMENT

Treatment of female infertility

Ovulation induction

Is aimed at the development

of more than one mature

follicle in a woman who is

anovulatory so that more

oocytes are available for

fertilization.

CON…

Before starting therapy the male partner semen must be analyzed. Clomiphene citrate has been used widely for induction of ovulation.

It stimulates the release of FSH.

Can be prescribed up to a maximum of

six cycles if ovulation occurring.

CON…

The dose depend upon the cause of anovulation, the female partner age and history of previous response or ovarian surgery. Usually started at 50 mg daily from day 2-6 of the menstrual cycle and increased up to 150 mg daily if there is no response. Women with PCOS respond to 25 mg daily from day 2-6 of cycle.

CON… Tamoxifen 20-40 mg from day 2-6 of cycle. Human chorionic gonadotropin (hCG).Gonadotropin releasing hormone (GnRH).Most of these drugs may be used alone or in a combination with others.

IVF: In vitro fertilization

Female reproductive system

Fertilization: Ova

+ Sperm

In vitro: in glass

Hormonal treatment

Female

Harvest the ovum

Mix in a test tube

Natural ejaculation

Collect semen

Mature Ova

Motile sperms

Keep to develop embryo

Transfer to motherMale

Basic Principle of IVF

In vitro fertilization (IVF)Most effective. Recommended when both fallopian tubes are blocked.

PREPARATION FOR IVF

Nutritional

About four to six weeks before each cycle of IVF you should begin thinking about your nutritional health. A healthy, balanced diet is very important as is adequate hydration (you should drink around two liters of water per day).

CON…

Foods to avoid are chocolate, processed foods and foods with high sugar content. You should try to eat at least 60 mg of protein a day, This is important because low levels of protein in your body can cause you to produce fewer eggs.

CON…

You should also reduce or cut out your consumption of caffeine and alcohol. If you are taking any prescription medication, make sure that your fertility specialist is aware of this.

CON…It can be a good idea to take a daily multivitamin, as certain vitamins can help you to produce eggs and create optimal conditions in your uterus for nurturing embryos. Talk to your fertility specialist before making any radical changes to your diet or starting on any course of vitamins or herbal supplements.

Physical

Being overweight or underweight can hamper your chances of getting pregnant through IVF, If you have either of these problems you should try to rectify them gradually and not via crash diets or highly strenuous exercise. Light exercise such as walking or yoga is safe, but aerobic exercise should be avoided.

CON…

Make sure that you avoid cigarettes and smoky atmospheres, as the chemicals in cigarette smoke can affect the lining of your uterus. Avoid sitting for long periods in the same position as this can restrict blood flow.

CON…

If you work on the computer all

day, make sure you get up once in a

while and walk around.

You should also avoid hot baths,

Jacuzzis and sun bathing.

CON…

keeping the abdomen warm with a

hot water bottle in the period

leading up to the egg-harvesting

and transfer stages can be helpful.

Don't use the hot water bottle after

transfer.

Mental

You must give yourself enough time to relax and recover from each cycle of treatment. If you try and live your life just as you did before you were having IVF, you will run into problems.

CON…

You need to accept the changes it brings about in your energy levels. Don't forget to spend time with your partner and communicate with him. You both will to talk about the IVF and your experiences, but also to focus on other things, the things you enjoy doing together.

Check your thyroid (my opinion is that your TSH should be below 2.0 for IVF) and have full bloodwork completed including antinuclear antibody, prolactin, ferritin, INR, prolactin, FSH, LH, DHEA-S and testosterone .

CON…

Get into a healthy sleep cycle for at least 1 month before your cycle, aiming for 8 hours of sleep. Take an omega 3 fish oil supplement. Omega 3 fatty acids have been shown to improve embryo morphology during IVF.

CON…

Take coenzyme q 10. Coenzyme

Q10 improves egg quality by acting

as a mitochondrial antioxidant. Aim

for approximately 400mg twice

daily.

COMPLICATION OF IVF

During ovarian stimulation, hyperstimulation syndrome may occur. premature delivery. Ectopic pregnancy may also occur if a fertilized egg develops outside the uterus. Multiple births.Birth defects.

GAMETE INTRAFALLOPIAN TRANSFER

Oocytes aspirated from follicles are mixed with washed sperm and placed in the uterine tube via laparoscopy. This approach appears to achieve a higher pregnancy rate than IVF. The pre-embryo travel toward the uterus, following natural time for implantation in 4 days.

ZYGOTE INTRAFALLOPIAN TRANSFER

These procedure are similar to GIFT

except transfer to the fallopian tube

occurs at the zygote stage about 16

to 18 hours after oocytes

insemination.

OVUM TRANSFER

A donor provides the ovum, which

is fertilized with the partner sperm.

The embryo is transferred into

infertile woman uterus after about 5

days via a small catheter.

Chronic cervicitis are cervical factor

causing infertility antibiotic given for

treatment.

Inadequate oestrogen stimulation

treated by administration of

oestrogen.

TREATMENT OF MALE INFERTILITY

Male fertility depend on sperm

quality rather than sperm number.

Hormonal treatment is not effective

unless the a diagnosis of

hypogonadotrophic hypogonadism

is the cause.

CON…

Antioxidant therapy ( vitamin E and vitamin C ) and the use of antibiotics in the presence of infection help to improve fertility. Varicocele ligation is indicated in symptomatic cases but improvement in fertility following surgery is not confirmed.

CON…

Assisted conception technologies

such as intracytoplasmic sperm

injection (ICSI) achieve better result

than other treatments.

NURSING MANAGEMENT The nurse has a major

responsibility for teaching

and providing emotional

support throughout the

infertility testing and

treatment period.

CON…

Providing information about the

reproductive process and infertility

evaluation and addressing the

psychologic and social distress that

can accompany infertility.

CON…

The nurse assisted during Assisted Reproductive Technology (ART). The nurse also play a role in promoting fertility, which includes teaching of prevention of infection, responsibility for infertility, early diagnosis and treatment.

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