Infertility.........................pptx

Health

1. 05/10/2009 1 WELCOME

2. Seminar on Infertility 05/10/2009 2

3. 05/10/2009 3 DEFINITION  Fertility is defined as the capacity to conceive or reproduce.  Infertility is defined as a failure to conceive within one or more years of regular unprotected coitus.  Infertility is the inability to achieve conception after one year of unprotected intercourse. 05 / 10 / 2009 3

4. 05/10/2009 4 INCIDENCE According to statistics by the Centers for Disease Control (CDC) 6.1 million women between the ages of 15 to 44 have an impaired ability to have children. 2.1 million married couples are experiencing infertility. 9.2 million women had made use of infertility services. 05 / 10 / 2009 4

5. 05/10/2009 5 INCIDENCE …..Contd. WHO survey report 2000 reveals Incidence of infertility as 12-13.5 % among married couples. 80 % of the couples achieve conception within one year of regular intercourse ( 4-5 times in a week )  10 % will achieve by the end of 2nd year 10 % will remain infertile by the end of 2nd year. 05 / 10 / 2009 5

6. 05/10/2009 6 TYPES OF INFERTILITY 1. PRIMARY INFERTILITY When a couple has never been pregnant either the woman has never conceived or the man has never fathered a child. 2. SECONDARY INFERTILITY Secondary infertility refers to women who have achieved pregnancy and given birth in the past, but are now having difficulty conceiving. 05 / 10 / 2009 6

7. 05/10/2009 7 TYPES OF INFERTILITY…..Contd. 3. IDIOPATHIC INFERTILITY No definite cause for the infertility can be found. 4. RECURRENT MISCARRIAGE Women who experience recurrent miscarriage may also receive a diagnosis of infertility if they experience two or more successive miscarriages. 05 / 10 / 2009 7

8. 05/10/2009 8 CAUSES OF INFERTILITY 05 / 10 / 2009 8

9. 05/10/2009 9 CAUSES OF INFERTILITY 1. ENDOMETRIOSIS • 1/3rd of infertile women have endometriosis • Endometrial tissue outside of uterus • Anatomic distortion, adhesions • Ovarian damage (endometrioma ) • “Substances” that impair ovulation, fertility, implantation 05 / 10 / 2009 9

10. 05/10/2009 10 CAUSES OF INFERTILITY Cont.... 2. TUBAL BLOCKAGE Due to PID because it leaves scar tissue & adhesions as a result of inflammation tubes may be kinked or twisted. 05 / 10 / 2009 10

11. 05/10/2009 11 CAUSES OF INFERTILITY Cont.... 3. PREVIOUS SURGERY Previous surgery like appendectomy, repair of a tube after ectopic pregnancy may cause adhesions or scaring. 4. Use of IUD or progesterone only oral contraceptives increases risk of ectopic pregnancy. 05 / 10 / 2009 11

12. 05/10/2009 12 CAUSES OF INFERTILITY Cont.... 5.OVULATION ANOMALIES (ANOVULATION ) Failure of the ovaries to produce, mature or release eggs is an imbalance of harmones . 05 / 10 / 2009 12

13. 05/10/2009 13 CAUSES OF INFERTILITY Cont.... CERVICAL MUCOUS PROBLEMS Hormonal deficiencies that maintain the thick acidic property of cervical mucus so it is hostile to sperm. 05 / 10 / 2009 13

14. 05/10/2009 14 CAUSES OF INFERTILITY Cont.... 7. INSUFFICIENT OESTROGEN & PROGESTERONE PRODUCTION Excessive androgen production, increased or decreased FSH, LH Levels. The production FSH stimulates follicle to ripen & causes the production of Progesterone. Production of estrogen is influenced by the levels of circulating prolactine from the pituitary gland. 8. IMMUNOLOGIC FACTORS 05 / 10 / 2009 14

15. 05/10/2009 15 CAUSES OF INFERTILITY Cont.... 9.VARICOCELE Is a varicose or swollen vein in the testicle. Swelling elevates the temperature within the testis. It retards or destroys the process of spermatogenesis. INCIDENCE –35 % in the infertile population. 10.COMBINED CAUSES 05 / 10 / 2009 15

16. 05/10/2009 16 FACTORS RESPONSIBLE FOR INFERTILITY 1. Coital frequency 2. Age 3. Smoking 4. Exercise and weight loss 5. Diet 6. Stress 7. Medical conditions 8. Use of drugs and chemicals 05 / 10 / 2009 16

17. 05/10/2009 17 FACTORS RELATED TO SPERM AND OVULATION Healthy spermatozoa ( male factor ) 2. The spermatozoa should undergo changes(capacitation,acrosome reaction ) and acquire motility. ( Cervical factor ) 3. The motile spermatozoa should ascend through the cervix into the uterine cavity and the fallopian tubes. 4 There should be ovulation.(Ovarian factor ) 05 / 10 / 2009 17

18. 05/10/2009 18 FACTORS RELATED TO SPERM AND OVULATION ……. Contd. 5. The fallopian tubes should be patent and the oocyte should be picked up by the fimbriated end of the tube. ( Tubal factor ) 6. The spermatozoa should fertilize the oocyte at the ampulla of the tube. 7. The embryo should reach the uterine cavity after 3-4 days of fertilization. 8. The endometrium should be receptive for implantation and the corpus Luteum should function adequately. 05 / 10 / 2009 18

19. 05/10/2009 19 INVESTIGATIONS OF INFERTILITY Objectives of investigations ♦ To detect the etiological factors. ♦ To rectify the abnormality in an attempt to improve the fertility. ♦ To give assurance with explanation to the couple if no abnormality is detected. 05 / 10 / 2009 19

20. 05/10/2009 20 BASIC INVESTIGATIONS MALE 1. HISTORY ♦ Age duration of marriage,history of previous marriage ♦ General medical history ♦ Surgical history ♦ Occupational history ♦ Sexual history ♦ Social habits 2 . EXAMINATION ♦ General and specific examination ♦ Seminal fluid analysis 05 / 10 / 2009 20

21. 05/10/2009 21 BASIC INVESTIGATIONS Contd … 05 / 10 / 2009 21

22. 05/10/2009 22 BASIC INVESTIGATIONS Contd … Normal semen values Volume 2.0 ml or more P H 7.2 – 7.8 Sperm concentration 20 million / ml or more Total sperm count > 40 million per ejaculate Motility 50 % or more progressive forward motility Morphology 15 percent or more normal form Viability 75 % or more living Leucocytes Less than 1 million / ml Sperm agglutination < 2 ( scale 0-3 ) 05 / 10 / 2009 22

23. 05/10/2009 23 BASIC INVESTIGATIONS Contd … MALE 3. INDEPTH EVALUATION ♦ Serum FSH, LH, Testosterone, Prolactin and TSH ♦ Fructose content in the seminal fluid ♦ Testicular biopsy 4 . TRANSRECTAL ULTRASOUND ( TRUS ) VASOGRAM IMMUNOLOGICAL TEST 05 / 10 / 2009 23

24. 05/10/2009 24 BASIC INVESTIGATIONS FEMALE 1. HISTORY ♦ General medical history ♦ Surgical history ♦ Menstrual history ♦ Previous obstetric history ♦ Contraceptive practice ♦ Sexual problems 2 . EXAMINATION ♦ General and specific examination ♦ Gynaecological examination ♦ Speculam examination 05 / 10 / 2009 24

25. 05/10/2009 25 BASIC INVESTIGATIONS Contd … 3 CONFIRMATION OF OVULATION The various methods used to detect are indirect,direct and conclusive. A. Indirect B. Direct C. Conclusive 05 / 10 / 2009 25

26. 05/10/2009 26 BASIC INVESTIGATIONS Contd ….. Indirect causes are – i. Menstrual history ii. Basal Body Temperature ( BBT ) Assessment  Temp to be taken with a special thermometer every morning before getting out of bed.  BBT increases slightly at ovulation & remain increased until menstruation or pregnancy.  BBTS are taken in same manner as for fertility control.  Evidence of follicle development, ovulation & corpus luteum development would be seen if temperature changes persisted for 12-14 days before menses.  Temperature chart for at least 4 cycles. 05 / 10 / 2009 26

27. 05/10/2009 27 BASIC INVESTIGATIONS Contd … iii. Cervical mucus study ♦ After ovulation the cervical mucus becomes thick & sticky and can be stretched between the fingers.( A sign known as spinbarkeit ) ♦ If the mucus is mixed with semen or contraceptive foams or an infection is present, the result may be inaccurate. Some women may feel uncomfortable touching their genitals and mucus. ♦ Cervical mucus examined at ovulation & after intercourse to determine whether changes occur that promote sperm penetration & cervical. 27

28. 05/10/2009 28 BASIC INVESTIGATIONS Contd … Postcotial test (Sims- Huhner ) Intercourse (2-12 hrs) for test Look at: pH, Sperm, Spinnbarkeit , Ferning Cellularity , Sperm Shaking, Sperm Agglutanation 05 / 10 / 2009 28

29. 05/10/2009 29 BASIC INVESTIGATIONS Contd … iv. Hormone estimation Testicular dysfunction causes rise in FSH and LH. Low level of FSH and LH suggest hypogonado trophic gonadism . Eleveted prolactin due to pituitary adenoma may cause impotency. 05 / 10 / 2009 29

30. 05/10/2009 30 BASIC INVESTIGATIONS Contd … v. Vaginal Cytology Maturation index shifts to the left from the midcycle to the midsecond half of cycle due to the effect of progesterone. vi. Endometrial Biopsy 05 / 10 / 2009 30

31. 05/10/2009 31 BASIC INVESTIGATIONS Contd … vii. Sonography Serial sonography during midcycle measures the graafian follicle before ovulation(18 to 20 mm) Features of ovulation seen are collapsed follicle and fluid in the pouch of douglas . Hysteriosalphigiography – To rule out uterine or tubal abnormalities. 05 / 10 / 2009 31

32. 05/10/2009 32 BASIC INVESTIGATIONS Contd … B. Direct - laproscopy C Conclusive - Pregnancy 05 / 10 / 2009 32

33. 05/10/2009 33 ADVANCED MANAGEMENT OF INFERTILITY COUPLE INSTRUCTIONS  Assurance  Body weight  Smoking and Alcohol  Coital problems MALE INFERTILITY TREATMENT 1. General care  Counselling  Use of vitamins E, C, D, B12.  Medications like Clomiphene citrate 25 to 50 mg orally for 25 days with rest for 5 days for 3 cycles. It increases of sr level of FSH, LH and testosterone.  In genetic abnormality artificial insemination of donor sperms. 05 / 10 / 2009 33

34. 05/10/2009 34 ADVANCED MANAGEMENT OF INFERTILITY Contd … MALE INFERTILITY TREATMENT 2. Surgical care  Microsurgeries like vasoepididymostomy or vasovasostomy if patient is azoospermic .  Correction of varicocele  Orchidopexy in undescended testies 3. Impotency  Psychosexual treatment  For erectile dysfunction sildenafil (25 to 100mg Assisted reproductive technology ( ART ) 05 / 10 / 2009 34

35. 05/10/2009 35 ADVANCED MANAGEMENT OF INFERTILITY Contd … FEMALE INFERTILITY TREATMENT 1. General care  Psychotherapy  Reduction of weight 2. Drugs  Medications like Clomiphene citrate 50 mg to 250 mg orally for 5 days for 6 cycles. It blocks the estrogen receptors in the hypothalamus  In genetic abnormality artificial insemination of donor sperms. 05 / 10 / 2009 35

36. 05/10/2009 36 ADVANCED MANAGEMENT OF INFERTILITY Contd … FEMALE INFERTILITY TREATMENT 3. Surgery  Laproscopic ovarian drilling ( LOD )  Tubal surgeries  Uterovaginal surgeries 05 / 10 / 2009 36

37. 05/10/2009 37 ASSISTED REPRODUCTIVE TECHNOLOGY 1.Intrauterine insemination ( IUI ) IUI may be either AIH ( Artificial insemination Husband ) or AD (Artificial insemination of donor or a combination of both. 05 / 10 / 2009 37

38. 05/10/2009 38 ASSISTED REPRODUCTIVE TECHNOLOGY Contd … Gamete intrafallopian transfer ( GIFT ) Both the sperm and unfertilised oocytes are transferred into the fellopian tubes. Zygote intrafallopian transfer ( ZIFT ) 05 / 10 / 2009 38

39. 05/10/2009 39 ASSISTED REPRODUCTIVE TECHNOLOGY Contd … INVITRO FERTILIZATION ( IVF) • IVF or In Vitro Fertilization is a method of assisted reproduction to increase the possibility of pregnancy. • As the term ‘in vitro fertilization’ or ‘test tube baby’ explains itself, it is the procedure to fertilize eggs with sperm outside the human body. 05 / 10 / 2009 39

40. 05/10/2009 40 ASSISTED REPRODUCTIVE TECHNOLOGY Contd … INDICATIONS OF IVF  Blocked or damaged fallopian tubes  Abnormal sperm,  Endometriosis or immunologic problems,  other infertility treatment,  Advanced maternal age. 05 / 10 / 2009 40

41. 05/10/2009 41 ASSISTED REPRODUCTIVE TECHNOLOGY Contd … Procdures of IVF & ET 1. Controlled Superovulation (COH) ( Clomiphene , hMG , uFSH , rFSH ) 2. Monitoring (Ultrasound, E2) 3. Egg retrieval & IVF (or ICSI) 4. Embryo culture 5. Embryo Transfer (ET) 6. Luteal phase support (progesterone) 7. Pregnancy test 05 / 10 / 2009 41

42. 05/10/2009 42 ASSISTED REPRODUCTIVE TECHNOLOGY Contd … 2. Ultrasound monitoring of follicles

43. 05/10/2009 43 ASSISTED REPRODUCTIVE TECHNOLOGY Contd …. 3. Ultrasound Guided Oocyte Retrieval

44. 05/10/2009 44 ASSISTED REPRODUCTIVE TECHNOLOGY Contd … Embryo Culture

45. 05/10/2009 45 ASSISTED REPRODUCTIVE TECHNOLOGY Contd … 5. Embryo Transfer 05 / 10 / 2009 45

46. 05/10/2009 46 ASSISTED REPRODUCTIVE TECHNOLOGY Contd … Intracytoplasmic sperm injection (ICSI) ICSI is a highly technical procedure designed to insert a sperm into the cytoplasm of egg using a thin glass tube under the special microscope with a manipulator. Indications: • Severe male factor infertility • Poor quality eggs with thickened shell (zona ) • Prior or repeated fertilization failure with standard IVF • Anti-sperm antibodies • Use of surgically retrieved sperm directly from the epididymis or testis 46

47. 05/10/2009 47 ASSISTED REPRODUCTIVE TECHNOLOGY Contd … Intracytoplasmic sperm injection (ICSI)

48. 05/10/2009 48 ALTERNATIVES TO INFERTILITY Surrogacy Embryos are transferred to the uterus of another woman who is willing to carry the pregnancy on behalf of the infertile couple. Adoption 05 / 10 / 2009 48

49. 05/10/2009 49 ETHICAL AND LEGAL ISSUES IN INFERTILITY 1. Artificial insemination by donor Proper consent of her husband is taken. 2. Surrogacy Proper consent of surrogate mother is taken. Total responsibility of rearing parents if child born with birth defects. 3. Frozen embryo Should not be bought or sold. 4. Issues related to donor insemination Use of only one donor for each attempt. Proper consent and contract accepting the resultant offspring as legal heir. 05 / 10 / 2009 49

50. 05/10/2009 50 APPLICATION OF NURSING THEORY HILEGARD E. PEPLAU THEORY OF INTERPERPERSONAL RELATION Details of the Hildegard ♦ Born in Pennsylvania in 1909. Started her carrier from a diploma nursing program in 1931. ♦ 1947 MA in psychiatric nursing from Colombia University, Newyork . ♦ 1953 Published book on interpersonal relationship in nursing. 05 / 10 / 2009 50

51. 05/10/2009 51 APPLICATION OF NURSING THEORY Contd …. ♦ In 1974 got retired & was recognized all over as a nurse. ♦ Nursing can be viewed as an interpersonal process as it involves interaction between two or more individual with a common goal. ♦ For developing interaction between nurse and patient the nurse has to choose sequential pattern and different skills and assume various roles etc. 05 / 10 / 2009 51

52. 05/10/2009 52 APPLICATION OF NURSING THEORY Contd … Four phases in interpernal relationship by peplau ♦ Oridentation :– Problem defining phase. ♦ Identification :– Selection of appropriate professional assistance. ♦ Exploitation :– Use of assistance for problem solving. ♦ Resolution :– Termination of professional relationship 05 / 10 / 2009 52

53. 05/10/2009 53 ROLE OF A NURSE IN INFERTILITY MANAGEMENT Involved with couples who undergoing fertility treatment. 2. Should be aware of the types of treatment that are currently available and stresses that the couple has endured during the process. 3. Reduce stress in relationship 4 Encourage co-operation, protect privacy. 5 Refer couple to appropriate resource when necessary. 05 / 10 / 2009 53

54. 05/10/2009 54 ROLE OF A NURSE IN INFERTILITY MANAGEMENT Contd … 6. Advice to couple to avoid smoking Emphasis on diet, exercise, stress reduction techniques, health maintenance and disease prevention programs. Psychological support Assist with different infertility treatments. Create awareness about ethical and legal issues. 05 / 10 / 2009 54

55. 05/10/2009 55 NURSING PROCESS Altered health maintenance related to ineffective coping mechanisms in one or both partners. Self-esteem disturbances related to loss of reproductive abilities. Knowledge deficit related to menstrual cycle, sexual physiology. Knowledge deficit related to advance management of infertility. Altered sexual pattens related to treatment procedures. 05 / 10 / 2009 55

56. 05/10/2009 56 Please do not give up. But do not wait too long. Where is a will, there is a way. THANK YOU