INFERTILITY

INFERTILITY

—  Infertility is the inability to achieve pregnancy within a period of one year of frequent, regular, unprotected cohabitation (intercourse).

—  Inability of a sexually active, non-contracepting couple to conceive naturally after one year of regular unprotected sexual intercourse (WHO, 2018)

—  Nigeria has a population of 193 million (WorldoMeters information, January 2018). 

—  Yet about 20-25 percent of local couples are childless (higher).

—  Constitutes up to 45% of all female consultations in medical institutions (Andrela  Terso, 2018).

INTRODUCTION

—  The feeling experienced by the infertile couples includes: depression, grief, guilt, shame, inadequacy with social isolation

—  Childlessness is a major social problem in Nigeria, and so the anxiety of a patient is genuine

—  A woman will go to any length to look for a child to keep her marriage intact.

—  Seen as mainly problem of women

—  Almost 50% of infertile couple is related to male partner(Nordicalagos.org)

 

          EPIDEMIOLOGY

—  Incidence Varies in different populations

—  Average incidence is about  15% globally.

—  Unexplained infertility constitutes about 15%- 20% of all cases.

—  The figure in Nigeria may be higher but mostly varies between 10 & 20 percent. 

          TYPES OF INFERTILITY

—  Primary and Secondary.

—  Primary infertility: this is when a woman is unable to bear a child, due to the inability to become pregnant.

—  Secondary infertility: if a  woman has previously been pregnant, regardless of the outcome (which may have been a premature or full-term delivery, spontaneous abortion, induced abortion or ectopic pregnancy), and is now unable to conceive, it is considered secondary infertility.

         

                           CAUSES OF INFERTILITY

                  

      Causes/Risk Factors of Infertility In Both Partners

—  Unknown

—  Psychological

—  Immunological incompatibility

—  Age

—  Smoking

—  Alcohol

—  Being overweight

—  Poor diet

—  Sexually transmitted infection

—  Exposure to chemical

—  Mental stress

     FEMALE REPRODUCTIVE ORGANS

CONCEPTION AND FERTILITY

—  The chance of conceiving in any given menstrual cycle is less than 20%

   Main Events needed for conception to take place:

—   Ovulation:

—  Fertilization:

—  Implantation:

Any condition that interferes with these events may result in infertility.

REQUIREMENTS FOR FEMALE FERTILITY

—  Vagina capable of receiving sperm.

—   Normal cervical mucus

—  Ovulatory cycles.

—  Patent Fallopian tubes

—  Uterus capable of developing and sustaining pregnancy

—  Adequate hormonal status to maintain pregnancy.

REQUIREMENT FOR FEMALE FERTILITY

—  Adequate sexual drive and sexual function

—  Normal immunologic responses to accommodate sperm and conceptus

—  Adequate nutritional and health status to maintain nutrition and oxygenation of placenta and fetus.

FEMALE CAUSES

MAIN CAUSES IN FEMALE

—  Ovulation disorders

                   -Premature ovarian failure

                   -Polycystic ovarian failure(pcos)

—  Hyperprolactineamia

—  Thyroids problem , HIV/ AIDS, cancers

—  Uterine abnormalities

—  Tubal condition

          -Tubal blockage

          -Sub mucosal fibroids

          -Endometriosis

          -Surgical interventions

Medication

          -Chemotherapy

          -Illegal drugs

          -Nonsteriodal anti-inflammatory drug

Congenital anomaly

THE MALE REPRODUCTIVE SYSTEM

REQUIREMENTS FOR MALE FERTILITY

—  Normal spermatogenesis – normal sperm count, motility and biologic structure and function.

—  a normal ductal system.

—  Ability to maintain an erection.

—  Ability to achieve a normal ejaculation.

—   Placement of ejaculate in the vaginal vault.

CAUSES OF MALE INFERTILITY

Testicular causes

—  Radiation(x-ray)

—  Trauma to the testes

—  Orchitis (inflamation of the testes)

—  Systemic disorders e.g dm

—  Abnormal sperm morphology

Secondary hypogonadism(low GnRH,FSH, LH)

—  Hypothalamic causes

—  Pituitary causes

OTHER CAUSES OF MALE INFERTILITY

—  Low sperm count

—  No sperm count

—  Altered sperm transport

—  Obstruction of vas deference

—  Congenital absence of vas deference

—  Vasectomy( sperm count reaches zero after 6 month)

—  Congenital  absence or obstruction of the epidydymis

—  Erectile dysfunction

—  Retrograde ejaculation

—  Antiandrogenic medication intake.

—  Infection (chlamydia, gonorrhea, mumps)

STEPS IN EVALUATING FEMALE INFERTILITY

—  Assessment of body mass index

—  History taking

—  menstrual history,

—  obstetric history,

—  contraceptive history,

—  family history, medical history,

—   social history- Coital practices,

—   Medical hx (e.g. genetic disorders, endocrine disorders)

—  Medications( e.g. hormone therapy)

STEPS IN EVALUATING FEMALE INFERTILITY

—  PHYSICAL EXAMINATION- Detailed head to toe examination

—  General exams.  Breast examination, formation , lumps, galactorrhoea,

—  Genital examination, (e.g. patency, intact or broken hymen, masses, tenderness)

—  Signs of hyperandrogenism (e. g. hirsutism, acne, clitoromegaly)

DIAGNOSTIC EVALUATION

—  Fertility hormone profile( LH, FSH, oestrogen, progesterone and prolactin)

—  Endometrial biopsy

—  Hysterosalpingogram (HSG).

—  Hysteroscopy + dye test

—  Temperature (BBT) Measurement

—  folliculometry

EVALUATION TEST FOR MALE INFERTILITY

—  Detailed head to toe assessment

—  Semen analysis

—  Sperm penetration assay

—  Urine analyses

—  Hormonal assay; to measure concentration of hormones: Testoterone, FSH and LH

—  Postcoital test (low validity) to establish ability of sperm to penetrate cervical mucus.

—  Anti-sperm antibodies

EVALUATION OF MALE INFERTILITY

Semen analysis (WHO GUIDELINE)

·        Volumes (1.5ml to 5.0ml)

·        Number of sperm present(>20 million /ml)

·        Sperm motility(>60%) and forward projection (more than 2 on a scale of 1 to 4)

·        Morphology (>60% normal forms)

·        presence of infection

MANAGEMENT

—  The cost of treatment is high.

—  Physical, financial and time commitment

This includes;

—  Medical management

—  Surgical management

—  Nursing management

 Also depends on;

The duration of infertility

The age of the partner

And the underlying pathological cause.

FERTILITY TREATMENT FOR MEN

—  Premature ejaculation

          -behaivoural approaches

          -medications

—  Variocele; surgical removal of varicose vein

—  Blockage of the ejaculatory duct

-         Sperm extraction from the testicles and injecting into an egg in laboratory

—  Surgery for epididymal blockage: a bypass can be performed called vaso- epididymostomy

Intracytoplasmic sperm injection (ICSI)

TREATMENT IN WOMEN

—  Ovulation disorder

-         Ovulation induction: Clomiphene citrate  to encourage ovulation

-         Metformin ( glucophage); for client who do not respond to above PCOS linked to insulin resistance

-         Human menopausal gonadotropin or hMG (repronex).

-         Human chorionic gonadotropin.

-         Follicle stimulating hormone

-         -Bromocriptine to stimulate ovulation by inhibiting prolactin   (parlodel)

SURGICAL MANAGEMENT

—  Laparoscopic surgery

—  Intrauterine insemination

—  Assisted reproductive tecnologies(ART)

                   -In-vitro fertilization (IVF)

                   -Gamate intrafallopian transfer (GIFT)

                   -zygote intrafallopian transfer (ZIFT)

                   -Donor eggs and sperms; must be free from           STDs/HIV

                   -Gestational carrier

—  Adoption

—  Fostering

TREATMENT OF FEMALE INFERTILITY

—  Intrauterine insemination

-procedure in which sperm are washed, concentrated and injected directly       into a woman’s uterus

-not recommended in cases of tubal blockage, poor egg quality and ovarian failure

-Most successful when coupled with drugs inducing ovulation.

-Success rate of 20% per cycle.

IN-VITRO FERTILIZATION (IVF)

•      Multiple matured eggs from a woman are retrieved,

•        Fertilized with a man’s sperm outside the uterus in the laboratory.

 Fertilized embryos are implanted in the uterus after three to five days of fertilization.

ART: GAMETE INTRAFALLOPIAN TRANSFER (GIFT)

—  Gift is a procedure that involves:

                   -ovarian stimulation

                   -retrieval of eggs

                   -placing a mixture of sperm and eggs directly into the woman’s fallopian tube

—  fertilization occurs in the fallopian tube

—  Success rates per egg retrieval are about 28%

 (higher than for IVF)

ART: ZYGOTE INTRAFALLOPIAN TRANSFER (ZIFT)

—  ZIFT, also called tubal embryo transfer, a variation of IVF

—  As with IVF, the actual fertilization takes place in a lab dish

—  Fertilized eggs are placed directly into a fallopian tube

ART: INTRACYTOPLASMIC SPERM INJECTION (ICSI)

—  involves single sperm injected into the egg

—  The woman is administered fertility drugs prior to the procedure to aid in the production of multiple eggs

—  Only active undamaged sperm are selected for injections

—  Eggs are observed to see if fertilization takes place (65%average)

—  Implantation into the uterus takes place within 72 hours after ICSI

—  Success rate ranges from 15% to 35% per egg retrieval.

NURSING MANAGEMENT

—  Role of nurses in infertility care cannot be over-emphasized:

—  Supportive care; counseling

—  Show empathy, be patient during interaction with couple.

—  Reinforce positive factors  necessary to achieve pregnancy

—  Importance of more frequent intercourse during ovulation of fertile periods.

—  Monitor ovulation using fertility awareness methods.

—  Instruct couple to avoid multiple sexual partners

Report early in cases of infection

NURSING MANAGEMENT: COUNSELING

—  Informed consent

—  Individual counseling and couple counseling

—  Provide coping strategies

—  Facilitate decision making as to dilemmas and decisions on right fertility treatment

—  Nutritional counseling and health education

—  Therapeautic communication to couples before , during and  after fertility treatment

NURSES ROLE

—  Need to obtain history and perform necessary examination regarding patient reports

—  Collect other information about tests reports and documents.

—  Coordinate plan of care with other health professional

—  Maintain privacy and confidentiality

—  Ensure follow up and supportive services to individual and familiy during counselling.

—  Help couple to consider non- medical options such as adoption.

—  Advocacy  and soliciting (inclusion of infertility care in NHIS package)

GENERAL ADVICE TO COUPLE

—  Sexual intercourse every 2-3 days

—  Smoking cessation

—  Reduction of alcohol intake

—  No caffeine

—  Folic acid supplement

—  Weight reduction

—  Stress reduction

—  Adequate dietary intake.

—  Vitamin supplement; zinc selenium and vitamin E

SUMMARY

—  Infertility is a significant social and medical problem affecting couples worldwide.

—  Female and male factors are equally responsible for infertility.

—  Evaluation of both partners is essential.

—   Treatment depends on the cause of infertility and varies from ovulation-inducing drugs to surgery to ART.

—   It is also advised that policy makers should subsidized the assistive reproductive therapy for accessibility and affordability to the populace. .

—   Never write off any couple.

REFERENCES

Akinloye O, Arowoloju AO, Shittu BO (2016); A Review Of Management Of Infertility In Nigeria: International Journal  On Women’s Health 2016: 3:265-275 Pmid:21892337

Anjani C, Andrella T. (2017). Infertility And Impaired Fecundity In The United States, 1982-2016: Data From The National Survey Of Family Growth. Hyattsville, Md.: U.S. Department Of Health And Human Services, Centers for Disease Control And Prevention, National Center For Health Statistics.

Kenneth I. Aston; Philip J. Uren; Timothy G. Jenkins; Alan Horsager; Bradley R. Cairns; Andrew D. Smith; Douglas T. Carrell (December 2015). " Fertility And Sterility. 104 (6): 1388–1397. Doi:10.1016/J.Fertnstert.2015.08.019. Pmid 26361204.

Salumets A, Nilsson T (2010). "Variations In Folate Pathway Genes Are Associated With Unexplained Female Infertility". Fertility And Sterility. 94 (1): 130–137. Doi:10.1016/J.Fertnstert.2010.02.025. Pmid 19324355.

World Health Organization( 2018): Prevalence Of Infertility And Its Management; “A Multi-dimensional Approach”

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