Download infertility - Annammal College of Nursing

Presented by,
Mrs.Kavitha Jasmine,
Asst. Prof,
Obstetrics & Gynecology Department,
Annammal College Of Nursing, Kuzhithurai.
Infertility is defined as a failure
to conceive within one or more
years of regular unprotected
coitus.
TYPES
Primary Infertility
Secondary Infertility
PRIMARY INFERTILITY: It denotes those
patients who have never conceived.
SECONDARY INFERTILITY: It indicates
previous pregnancy but failure to
conceive subsequently.
INCIDENCE
Eighty percent of the couples achieve
conception if they so desire,within one
year of having regular intercourse with
adequate
frequency(4-5
times
a
week).Another 10 percent will achieve the
objective by the end of second year.As
such,10 percent remain infertile by the end
of second year.
CAUSES OF INFERTILITY
MALE FACTORS
Defective
spermatogenesis
 Obstruction
of
efferent
duct
system.
 Failureto deposit
sperm high in
vagina.
 Errors in seminal
fluid.
FEMALE FACTORS
 Ovarian factor.
 Tubal & peritoneal
factors.
 Uterine factors.
 Cervical factors.
 Vaginal factors.
 Combined factors.
MALE REPRODUCTIVE SYSTEM
DEFECTIVE SPERMATOGENESIS
 CONGENITAL FACTORS
 UNDESCENDED TESTES
 KARTARGENER SYNDROME
 HYPOSPADIAS
 THERMAL FACTORS
 INFECTION
 GENERAL FACTORS
 ENDOCRINE FACTORS
 GENETIC FACTORS
 IMMUNOLOGIC FACTORS
CONGENITAL FACTORS:
Undescended
testes- The hormone
secretion
remains
unaffected,
but
spermatogenesis is depressed.Vas deferens
is absent in about 1-2 percent males.
Kartagener syndrome- It is an autosomal
disease in which there is loss of ciliary
function and sperm motility.
Hypospadiasis- Causes failure to deposit
sperm high in vagina.
THERMAL FACTOR:
Scrotal temperature is raised in
conditions such as varicocele,big hydrocele or
filariasis. Other causes are using tight under
garments or working in hot sun. In all these
cases the depressed spermatogenesis may be
temporary and reversible.
INFECTION:
Infections like mumps, bronchiectasis
bacterial or viral infection of SEMINAL
VESICLE OR PROSTATE depresses sperm
count.
GENERALFACTORS:
Chronic diseases,malnutrition or heavy
smoking reduce spermatogenesis.Alcohol also
has the same effect.
IATROGENIC:
Radiation,cytotoxic drugs, nitrofurantoin,cimetidine,
βblockers,
anti
hypertensives,anti
convulsants
and
antidepressant drugs are likely to hinder
spermatogenesis.
OBSTRUCTION OF EFFERENT DUCTS
The efferent ducts may be obstructed by
infection like tubercular , gonococcal or by surgical
trauma(herniorraphy) following vasectomy.
FAILURE TO DEPOSIT SPERM HIGH IN VAGINA
Ercetile dysfunction, Ejaculatory defectpremature ejaculation, retrograde or absence of
ejaculation.
Hypospadias:
A developmental anomaly in the male in
which the urethra opens on the underside of penis
or in the perineum.
ERRORS IN SEMINAL
FLUID
1.Usually high or low
volume of ejaculate.
2.Low fructose content.
3.High prostaglandin count.
4.Undue varicosity.
DEFECTIVE SPERMATOGENESIS
VARICOCELE
OVARIAN FACTORS
 ANOVULATION
 OLIGOOVULATION
 LUTEAL PHASE DEFECT
 LUTEINISED UNRUPTURED
FOLLICULAR
SYNDROME
ANOVULATION OR OLIGO-OVULATION:
Ovarian function is likely to be
linked with disturbed hypothalamopituitary-ovarian axis either primary or
secondary from thyroid or adrenal
dysfunction.
Thus, the disturbance may result in
anovulation, or even amenorrhoea.As
there is no ovulation, there is no corpus
luteum formation.
LUTEAL PHASE DEFECT(LFD):
In this condition there is inadequate
growth and functioning of corpus luteum. There
is inadequate progesterone secretion.The life
span of corpus luteum is reduced to 10 days.As a
result,there is inadequate secretory changes in
the endometrium which hinders implantation
Drug induced ovulation,decreased level of FSH
and
LH,
elevated
prolactin,subclinical
hypothyroidism,older
women,pelvic
endometriosis,dysfunctional uterine bleeding are
the important causes.
LUTEINISE UNRUPTURED
FOLLICULAR SYNDROME
(trappedovum):
In this condition the ovum is
trapped inside the follicle which gets
luteinized.The causes may be
associated with pelvic endometriosis
or with hyperprolactineamia.
CERVICAL FACTORS
OVARIAN & TUBAL
FACTORS
Tubal factors:
Are responsible for about 30-40 percent cases of
female infertility. It is due to obstruction in the tube
due to;
1.Peritubal adhesions
2.Endosalpingeal damage
3.Previous tubal surgery or sterilization
4.Salpingitis
5.Tubal endometriosis
6.Polyps or mucous debris in the tubal lumen
7.Tubal spasm
Peritoneal causes:
Minimal endometriosis, dyspareunia,
abnormal peritoneal fluid are the peritoneal factors.
Uterine factors:
The endometrium must be sufficiently
receptive enough for effective nidation and growth
of fertilized ovum.The possible factors that hinders
nidation are:1.Uterine hypoplasia
2.Inadequate secretory endometrium
3.Fibroid uterus
4.Congenital malformation of the uterus
Cervical factors:
Congenital elongation of cervix,second
degree
uterine
prolapse,acute
retroverted
uterus,abnormal composition of cervical mucous.
Vaginal factors:
It includes;
1.Atresia vagina
2.Transevrse vaginal septum
3. Septate vagina
4. Narrow introitus
COMBINED FACTORS
 Apareunia And Dyspareunia
Anxiety And Apprehension
Use Of Lubricants During
Intercourse Which Are
Spermicidal
Immunologic Factors
Combined factors:
These include the presence of factors both in male
and female partners causing infertility.
General factors:
Advanced age of wife beyond 35 is related but
spermatogenesis continues throughout life although
ageing reduces the fertility in males.
Infrequent intercourse, lack of knowledge of coital
technique and timing of coitus to utilize the fertile
period are common even among the literate couples.
Apareunia and dyspareunia
Anxiety and apprehension
Use of lubricants during intercourse which may be
spermicidal.
INVESTIGATIONS OF INFERTILITY
OBJECTIVES ;
1.To detect the etiological factors.
2.To rectify the abnormality in an
attempt to improve the fertility.
3.To give assurance with explanation to
the couples, if no abnormality is
detected.
INVESTIGATION IN MALES
History collection:
Age, duration of marriage,history of previous
marriage,and proven fertility if any,are to be noted.
A general medical history should be taken with special
reference to sexually transmitted diseases,mumps
orchitis after puberty, diabetes,& recurrent chest
infection.
Relevant surgeries such as herniorrhaphy, surgeries on
testes or genital area are to be enquired.
Occupational history should be directed towards
exposure to excessive heat or radiation.Social
habits,particularly heavy smoking and alcohol is to be
collected.
Examination:
•A full physical examination is to be
performed to determine the general
health condition.
•Examination of reproductive system
includes inspection and palpation of
genitalia.
•Presence of varicocele should be
elicited in upright position.
VARICOCELE
A.Routine Investigations include urine and blood
examination including postprandial sugar.
B.Seminal Fluid Analysis: This should be the first
step in investigation because if some gross are detected
like absence of sperm,the couple should be counselled
for the need of assisted reproductive therapy.
C.Collection: Collection of semen is done by
masturbation failing which by coitus interruptus.The
semen is collected in a clean wide mouthed jar.The
sample must be send to lab as early as possible so that
examination is conducted witnin 2 hours.
INDEPTH EVALUATION:
These are needed for the cases of –a)Azoospermia
b)Oligospermia c)Low volume ejaculate d)Problems of
sexual potency etc.
.SERUM FSH,LH, TESTOSTERONE,PROLACTIN & TSH:
Testicular hypogonadotropic hypogonadism.Elevated
prolactin due to pituitary adenoma may cause impotency.
.FRUCTOSE CONTENT IN SEMINAL FLUID: Its absence
suggest congenital absence of seminal vesicle or portion of
ductal system or both.
.TESTICULAR BIOPSY: It is done to differentiate primary
testicular failure from obstruction as a course of
azoospermia or severe oligospermia.The biopsy material is
to be sent in Bouin’s solution.
Transrectal Ultrasound(TRUS): is done to
visualize the seminal vesicles, prostate and ejaculatory
duct obstruction.
Indications of
TRUS are-Azoospermia or
oligospermia, abnormal digital examination, ejaculatory
duct abnormality and genital abnormality like
hypospadias.
Vasogram: is a radiographic study done to evaluate
the ejaculatory duct obstruction.It is mostly replaced by
TRUS.
karyotype analysis: This is done in case with
azoospermia or severe
oligospermia and raised
FSH.Klinefelter’s syndrome (XXY) is the commonest.
VASOGRAM
INVESTIGATION IN FEMALES
 HISTORY COLLECTION
 EXAMINATIONS
 SPECIAL INVESTIGATIONS
-INDIRECT DIAGNOSIS OF
OVULATION
-DIRECT DIAGNOSIS OF
OVULATION
DIAGNOSIS OF OVULATION
1.Direct method
2.Indirect method
Indirect method includes collection of
menstrual history, Basal body temperature,
Cervical mucous study,endometrial pH and
hormone study.
Directmethod includes
 Laparoscopy




Dilatation & Insufflation Test
Hysterosalphingography
Laparoscopy &Chromopertubation
Sonohysterosalphingography
LAPAROSCOPY;
Laparoscopic visualization of recent corpus luteum
or detection of ovum from the aspirated peritoneal fluid
from the pouch of douglas is the only direct evidence of
ovulation.
The scope of diagnostic laparoscopy has
been widened.It is an invasive investigation,so this is done
after male factor and ovulatory functions have been fonud
normal or corrected.
The indications of its use are;
a.Abnormal HSG findings.
b.Failure to conceive after reasonable
period(6
months) even with normal HSG.
c.Unexplained infertility.
d.Age above 35 years.
INDICATIONS FOR LAPAROSCOPY IN INFERTILITY
Diagnostic
- Age above 35 years.
- Abnormal HSG.
- Failure to conceive after reasonable
period with normal HSG.
- Unexplained infertility.
Operative Gift & Zift Procedures.
-Ovarian diathermy
-Reconstructive tubal surgery.
- Fulguration of endometriotic
implants.
PROTOCOLS:
A double puncture technique is to be applied.All the pelvic
organs are to be properly visualized,of particular importance is to
note the fimbrial end of fallopian tubes and their relation with the
ovaries.Proper documentation with the aid of diagram is mandatory.
Advantages Over Hsg:
It can precisely diagnose peritubal adhesions,pelvic endometriosis
or evidence of ovulation.Chromopertubation with methylene blue
cannot only reveal patency of the tube but the nature of tubal
motility.
Drawbacks: It is more invasive than HSG.It cannot detect
abnormality in the uterine cavity or lumen of tube.
When to be done? It is preferably done in the secretory
phase.Recent corpus luteum may be visualized and endometrial
biopsy can be taken in the same setting.
LAPAROSCOPY
LAPAROSCOPY
INSTUMENTS USED IN LAPAROSCOPY
DILATATIONAND INSUFFLATION TEST(RUBIN’S TEST)
Principle:
The underlying principle lies with the fact that cervical canal is in continuity
with the peritoneal cavity through the tubes.As such entry of air or CO2 into
the peritoneal cavity when pushed transcervically under pressure gives
evidence of tubal patency.
When to be done? It should be done in the post menstrual phase atleast 2
days stopping of menstrual bleeding.
LIMITATION:
It should not be done in the presence of pelvic infection.
OBSERVATIONS:
The patency of the tube is confirmed by:
1.Fall in pressure when raised above 120mm hg.
2.Hissing sound heard on auscultation on eithr iliac fossa.
3.Shoulder pain experienced by the patient.
Drawbacks:
In about one third of cases it gives a false negative findings due to corneal
spasm.It also cannot identify the side and site of block in the tube.
HYSTEROSALPINGOGRAPHY
HYSTEROSALPHINGOGRAPHY
Principle:
The principle is sams as that of
insufflation test,instead of air or CO2,dye is
instilled transcervically.
When to be done? 2 days after stopping of
menstrual bleeding.
Advantages:
It has got many advantages over
insufflations test.It can precisely detect the
side and site of block in the tube.It can
reveal any abnormality in the uterus like
congenital anomalies,fibroid etc.
HYSTEROSCOPY
CHROMOPERTUBATION
SONOHYSTEROSALPHINGOGRAPHY
Normal saline is pushed within the uterine cavity
with a paediatric Foley catheter.The catheter balloon is
inflated at the level of cervix to prevent fluid leak.USG
of the uterus and fallopie tube is done.Ultrasound can
follow the fluid through the tubes up to the peritoneal
cavity and in the pouch of Douglas.
Advantages:
It is a non-invasive method .
It can detect uterine abnormality and polyps.
Tubal Pathology could be detected.
There is no radiation exposture.
PREVENTION OF INFERTILITY
 Assurance To The Couples
 Body Weight Should Be
Adequate
 Smoking & Alcoholism Is
Prevented
 Managing Coital Problems
1.ASSURANCE:
The infertile couples remains psychologically
disturbed right from the beginning, more so as the
investigations proceeds.The couple in such cases should
be tactfully handled to minimize psychologic upset.
When minor defects are detected in both the
husband and the wife,each of which alone could not
cause infertility but in combination,they significantly
reduce the fertility potential.As such,the faults should be
treated simultaneously and not one afer the other.
2.BODY WEIGHT:
Overweight or underweight of any partner should
be adequately dealt with to obtain an optimal
weight.Body mass of index of 20-24 is optimum.
3.SMOKING AND ALCOHOL:
Excess smoking or alcohol consumption is to be
avoided.
4.COITAL PROBLEMS:
The coital problems must be carefully evaluated
by intelligent interrogation.Advice to have intercourse
during the midcycle too often gives a result early
enough even prior to investigation.Using LH test kit,one
can detect LH surge in urine by getting a deep blue
colour of dipstick.The test should be performed daily
between day 12 to day 16 of a regular cycle.Timed
intercourse over24-36 hours after the colour change
reasonably succeeds in conception.Minor psychosexual
problems should be corrected accordingly.
TREATMENT OF MALE INFERTILITY
The treatment of male is indicated in:
1.Extreme oligospermia
2.Azoospermia
3.Low volume ejaculate
4.Impotency
GENERAL MEASURES:
Reduction of weight in obese.
Avoidance of alchohol and heavy smoking.
Avoidance of tight and warm undergarments.
Avoidance of occupation that may elevate
testicular temperature.
Use of vitamins E,C,D,B12 and folic acid as
antioxidants to improve spermatogenesis.
Medications
that
interfere
with
spermatogenesis must be avoided like
nitrofurantoin,cimetidine,antihypertensives,anti
convulsants & anyidepressants.
SURGICAL MEASURES
When the patient is found to be azoospermic
and yet testicular biopsy shows normal
spermatogenesis, obstruction of vas must be
suspected. This should be corrected by
microsurgery-Vaso
Epididymostomy
or
Vasovasostomy.
The presence of varicocele is corrected by high
ligation of spermatic vein and the hydrocele by
surgey.
Orchidopexy in undescended testes should be
done between 2-3 years of age to have adequate
spermatogenesis in later life.
IMPOTENCY
Psychosexual treatment may be of help Hyper
prolactinaemia needs further investigation and
treatment.For erectile dysfunction
SILDENAFIL (25-100 mg) or TADALAFIL(10-20mg) is
currently advised. A single dose is given orally one hour
before sexual activity.In unresponsive
cases,artificial
insemination is to be adopted.
ASSISTED REPRODUCTIVE TECHNOLOGY
(ART) (FOR MALE INFERTILITY)
Prospect of male infertility has
improved significantly with the treatment available for
infertile males.
MANAGEMENT OF FEMALE INFERTILITY
GENERAL MEASURES
PHARMACOLOGICAL
MANAGEMENT
SURGICAL
MANAGEMENT
TREATMENT FOR ANOVULATION
Anovulation is a common factor for female
infertility. It may be present in
otherwise
normal
menstrual cycle or may be associated with
oligomenorrhoea or amenorrhoea.
INDUCTION OF OVULATION
1.General Measures
2.Pharmacological Management
3.Surgical Management
GENERAL MEASURES:
-Psychotherapy to improve the emotional stability.
-Reduction of weight in obesity as in PCOS cases
is essential to have a good response of drug therapy in
induction of ovulation.
PHARMACOLOGICAL MANAGEMENT:
1.CLOMIPHENE CITRATE:
Patient selection:
Normogonadotrophic-normoprolactinaemic patients who are having
normal cycles with absent or infrequent ovulation.
PCOS cases with oligomennorhoea or amenorrhoea
Hypothalamic amenorrhoea following stress or using oral
contraceptive pills.
Dose:
Clomiphene citrate is simple,safe and at the same time costeffective.Initial dose of 50mg daily.Dose can be increased to a
maximum of 250 mg daily if ovulation is not induced by lower
dose.The actual starting day of its administration in the follicular
phase varies between day 2 and day5 and therapy is given for 5
days.Ovulation is expected to occur about 5-7 days after the last day
of therapy.Therapy for 6 cycle is generally given
Mechanism of action of clomiphene citrate:
Clomiphene citrate is an anti-oestogenic drug.It blocks the
oestrogen receptors of hypothalamus.This results in increased GnRH pulse
amplitude causing increased gonadotropin secretion from the pituitary.
Side effects:
1.Hot flushes
2.Nausea
3.Vomiting
4.Headache
5.Visual disturbances
6.Ovarian hyperstimulation
Couple Instructions:
The couple is adviced to have sexual intercourse as per following
guidelines:
Daily or on alternative days beginning 5-7days after the last dose of
clomiphene therapy.
Several times for 24-48 hours after the colour change in urine when tested
by LH kit.
Number of times over 24-36 following hCG administration.
2.GONADOTROPHINS:
Indications:
Hypogonadotrophic hypogonadism
Clomiphene failed or resistant cases
Unexplained infertility
Dose schedule:
Dose schedule starts with a minimal dose of 75 IU IM/day.
Follicular stimulation is started at any time from 2-5 days of the cycle and
is continued for 7-10 days depending on the response.
Follicular growth is monitored with serum estradiol estimation and
follicular number and size are measured by transvaginal sonography.
Serum oestradiol level of 500-1500 pg/ml and maximum follicular
diameter of 18-20mm are optimum.
When this optimum level is obtained,5000-10000IU of hCG is
administered IM to induce ovulation.
Ovulation is expected to occur approximately 36 hours after hCG
administration.
Side effects
therapy:
of
gonadotrophin
Primary
ovulation
failure
with raised serum FSH.
Uncontrolled
thyroid
and
adrenal dysfunction.
Sex hormone dependent tumour
in the body.
SURGICAL MANAGEMENT
 Laparoscopic Ovarian Drilling
 Wedge Resection
 Surgery Of Pituitary
Prolactinomas
 Surgical Removal Of Ovarian
And Adrenal Tumours
 Tubal Surgery
1.Laproscopic
ovarian
drilling(LOD)
or
laser
vapourisation:
This is done by multiple puncture of the cysts in polycystic
ovarian syndrome by diathermy or laser.It reduces systemic and
intraovarian androgen levels.This procedure is helpful in clomiphene
resistant,hyperandrogenic anovulatory women.The woman ovulates
spontaneously following LOD.
2.Wedge resection:
This is not commonly done these days. Bilateral wedge
resection of the ovaries is done in PCOS cases where clomiphene
citrate fails to induce ovulation.It induces adhesions.
3.Surgery for pituitary prolactinomas.
4.Surgical removal of virilising or other functioning ovarian or
adrenal tumours.
5.Tubal surgery
TUBAL SURGERY
Indications for tubal surgery:
1.Peritubal adhesions
2.Proximal tubal block
3.Distal tubal block
4.Mid tubal block
Guidelines for tubal surgery:
Tubal surgery may be considered in young women after previous tubal
sterilization or in women with mild disease at the distal tubal segment.
Tubal surgery may be tried for mild proximal tubal block.
Preoperative assessment and planning for surgery has to be done by HSG or
laparoscopy.
Prior counseling of the couples about the hazards of surgery and prospect of
future pregnancy should be done.
IVF is considered as the best treatment option for any complicated tubal
occlusive disease.
Salphingectomy should be done before IVF when hydrosalpines are present.
Methods of tubal surgery:
Tuboplasty is the name given to finer
surgery on the tubes to restore the anatomy
and physiology as far as practicable.
The operation can be done by
conventional methods or by microsurgical
techniques which may be employed following
laparotomy.
Microsurgical techniques gives better results
due to minimal tissue handling and
damage,perfect haemostasis and minimal
adhesions.
TUBOPLASTY OPERATIONS
Salphingo-ovariolysis
Separation or division of adhesions.
Fimbrioplasty
Separation of fimbrial adhesions to open up the
abdominal ostium.
Salphingostomy
Creates a new opening in the completely occluded
tube.It is called terminal or cuff at the abdominal
ostium.
Tubotubal Anastomosis
When the segment of the diseased tube is resected
following tubectomy,an end to end anastomosis is
done.
Tubocornual Anastomosis
When there is corneal block, the remaining healthy
tube is anastomosed to the patent interstitial part of
the tube.
ADJUVANT THERAPY
Adjuvant procedures to improve the result of
tubal surgery include prophylactic antibiotics,use of
adhesion prevention devices(intercede,seprafilm) and
postoperative hydrotubation.
Hydrotubation:
Hydrotubation is the procedure to flush the tubal
lumen by medicated fluids passed transcervically
through a cannula. The fluid contains antibiotics and
hydrocortisone(Gentamicin-80mg and dexamethasone
4mg in 10ml distilled water). It should be done in
postmenstrual phase.
SALPHINGO OVARIOLYSIS
TUBO TUBAL ANASTOMOSIS
TUBOCORNUAL ANASTOMOSIS
ARTIFICIAL INSEMINATION
1.IUI- Intrauterine Insemination
2.Fallopian Tube Sperm Perfusion
1.INTRA UTERINE INSEMINATION
IUI may be either AIH(artificial insemination husband) or
AID(artificial insemination donor).Husband’s sperm is commonly
used.The purpose of IUI is to bypass the endocervical canal which is
abnormal and to place increased concentration of mobile sperms as close
to the fallopian tubes.
INDICATIONS FOR IUI:
1.Hostile cervical sperm
2.Cervical stenosis
3.Oligospermia
4.Immune factor (Male & Female)
5.Male factor-impotency or anatomical defects
6.Unexplained infertility
Washing,centrifuge and swim-up methods are commonly
used.About 0.3ml of washed and concentrated sperm is injected
through a flexible polyethylene catheter within the uterine cavity
around the time of ovulation.Washing in culture media removes the
proteins and prostaglandins from the semen that may cause uterine
cramps or anaphylactic reactions.
The processed motile sperm for insemination should be
atleast 1 million. Fertilizing capacity of spermatozoa is 24-48
hours. The procedure may be repeated 2-3 times over a period of
2-3 days.
TIMING OF IUI:
Spontaneous cycles: IUI likely on day 12 and 14.
Clomiphene Citrate induced cycles: IUI at 5-7 days after
completion of cycles.
Urinary LH detection: IUI done in 24 hours after colour change.
COLLECTION OF SEMEN FOR IUI:
1.The total number of days since last ejaculation should be no longer
than 4-5 days.Sperm cells are made and replaced rapidly after each
ejaculation.
2.Collect the semen using sterile techniques.Bacterias that are
normally found in the skin can contaminate the specimen.
3.Masturbation is the preferred method of collection.It ensures the
cleanest possible sample.
4.Donot have intercourse for 2-3 days before the day of collection.
5.Your appointment of sperm collection will be 70-90 minutes before
the insemination.
7.The specimen must reach the lab within 30 minutes after collection
of specimen.
8.Only containers distributed by the ANDROLOGY LABORATORY
must be used for collection.
PREPARATION FOR IUI:
1.PREPARING THE SEMEN SAMPLE: The semen should be washed
in a way that separates a highly active normal sperm from lower
quality sperm.
2.MONITORING FOR OVULATION: Ovulation can be calculated
using basal body temperature,LH kits and trans vaginal ultrasound.
3.DETERMINIG OPTIMAL TIMING: Most IUIs are done after one or
two days of detecting ovulation.
ADVANTAGES OF IUI:
IUI is the least invasive,effective,simple,cheap and first line assisted
conception treatment method for infertility couples.
Woman’s cervicel mucus can sometimes kill the sperm,preventing
the sperm from reaching the egg.Here IUI is the effective method.
IUI helps to deliver much more motile sperms to the fallopian tubes
at the critical times around ovulation.
IUI is cost effective and simplest method in advanced infertility
treatment.
DISADVANTAGES OF IUI:
High risk of generating OHSS-Ovarian Hyper Stimulation Syndrome.
Stimulated ovarian cycle in IUI can cause multiple pregnancy.
Ovarian cysts as the side effect of stimulated ovarian cycle.
Possibility of using wrong semen samples.
Noninfective salphingitis and allergic rection can occur.
70-80 percent chance for abortion or ectopic pregnancy.
AFTER CARE OF IUI:
Patient should be kept in Foot end elevated position after the procedure.
She should be adviced to take rest for 10-20 minutes following the
procedure.
Vital signs should be monitored immediately after the procedure.
Complete bedrest for 4-5 days after IUI.
No exercise exept light walking for 2 weeks after IUI.
Intake lot of protein rich foods like eggs,soya,chicken products ie atleast
75gm of protein per day.
Keep a positive frame of mind and pray to GOD to help you at this time.
After IUI,keep your stomach coverted and protected from wind for
atleast 2 weeks since the womb needs to stay warm to aid conception.
INTRA UTERINE INSEMINATION
INDICATIONS OF IUI
 Hostile Cervical Sperm
 Cervical Stenosis
• Oligospermia
 Immune Factor
 Male Impotency And
Anatomical Defects
 Unexplained Infertility
ASSISTED REPRODUCTIVE TECHNOLOGY(ART)
ART encompasses all the
procedures that
involve manipulation of gamates and
embryos
outside the body for the treatment of
infertility.
PRINCIPAL STEPS IN ART
 REGULATION USING Gnrh AGONIST.
 Controlled Ovarian Hyperstimulation.
 Monitoring Of Follicular Growth.
 Oocyte Retrieval.
 Fertilization Invitro.
 Transfer Of Gamrates Or Embryo.
 Luteal Support With Progesterone.
DIFFERENT METHODS OFART:
IVF-ET: In Vitro Fertilisation and Embryo Transfer
GIFT: Gamate Intra Fallopian Transfer
ZIFT: Zygote Intra Fallopian Transfer
POST: Peritoneal Oozyte & Sperm Transfer
SUZI: Subzonal Insemination
ICSI: Intra Cytoplasmic Sperm Injection
INVITRO FERTILISATION AND EMBRYO
TRANSFER(IVF-ET)
The field of reproductive medicine has changed
for ever with the birth of Louise Brown in 1978 by IVF-ET.Patrick
Steptoe and Robert Edwards of England are remembered for
their revolutionary work.
INDICATIONS OF IVF:
Tubal disease
Unexplained infertility
Endometriosis
Male factor infertility
Cervical hostility
Failed ovulation induction
Ovarian failure
Woman with normal ovaries but no functional uterus.
Woman with genetic risk
PATIENT SELECTION:
Age less than 35 years.
Presence of ovarian reserve (serum FSH < 10 IU/L)
Husband –normal seminogram
Couple must be screen negative for HIV and hepatitis.
Normal uterine cavity as evaluated by hystreroscopy.
PRINCIPAL STEPS OF AN ART CYCLE:
1.Regulation using GnRH agonist.
2.Controlled ovarian hyperstimulation.
3.Monitoring of follicular growth.
4.Oocyte retrieval.
5.Fertilisation invitro (IVF,ICSI GIFT)
6.Transfer of gamates or embryos.
7.Luteal support with progesterone.
IN VITRO FERTILIZATION
IVF-ET
TEST TUBE BABY-DISAMBIGUATION
GAMATE INTRA FALLOPIAN
TRANSFER-(GIFT)
GAMATE INTRA
FALLOPIAN
TRANSFER
GIFT was described by Asch and
colleagues in 1984.
It is a more invasive and
expensive procedure than IVF but the
result seems better than IVF.In this
procedure both sperm and unfertilized
oocyte are transferred into fallopian
tubes.Fertilisation is then achieved in vivo.
GIFT
ZYGOTE INTRA FALLOPIAN
TRANSFER
ZIFT was first described by Devroey et al, in
1986. The placement of the zygote (following one
day of in vitro fertilization) into the fallopian tube
can be done either through the abdominal ostium
by laparoscopy or through the uterine ostium
under ultrasonic guidance.
This technique is a suitable alternative of
GIFT when defect lies in the male factor or in
cases of failed GIFT.
ZIFT
ZIFT
INTRA CYTOPLASMIC SPERM INJECTION
ICSI was first described by Van Steirteghem and colleagues
in 1992.
Indications:
1.Severe oligospermia (less than 5million sperm/ml)
2.Presence of sperm antibodies
3.Obstruction of efferent duct system
4.Congenital absence of vas
5.Failure of fertilization in IVF
Technique:
One single spermotozoan or even a spermatid is injected
directly into the cytoplasm of an oocyte by miropuncture of the
zona pellucida.This procedure is carried out under a high quality
inverted operating microscope Micropipette is used to hold the
oocyte while the spermatozoan is deposited inside the ooplasm by an
injecting pipette.
INTRA CYTOPLASMIC SPERM INJECTION
INTRA CYTOPLASMIC SPERM INJECTION
HAZARDS OF ART
Most of the ART are associated with
increased chromosomal abnormalities of
the offsprings.
Increased
number
of
pregnancy
loss,multiple pregnancy and ectopic
pregnancy have been observed.
Perinatal mortality and morbidity are
high.
Psychological stress and anxiety of the
couple are severe.
Role Of Nurse
Midwife In
Infertility
Management
Nurse midwife comes from a variety of
training backgrounds,but the vasy majority
have previous experience in women’s health
care.
Nurses have to work diligently to help the
specialist execute treatment plans and play
an important role in supporting the patients
through the complex journey of infertility
treatment.
The nurse will aid the patient in
scheduling various investigations like
Ovarian
reserve
testing
,Hysterosalphingogram,
&
Semen
analysis.Infertility
testing
and
treatment involves specific timing
aroumd the menstrual cycle.For some
patients this may be unpredictable,So it
requires efficient and effective action
from the nurse.
The nurse have to instruct the
couples about schedules far taking the
medicines.Should provide teaching on
self subcutaneous and intramuscular
injection.For many patients this is the
first time they have had to give self
injections.Nurses do an outstanding
job at making sure thattreatment
plans are effectively delivered.
The diagnosis and treatment of infertility
involves significant stress that is
comparable to being diagnosed with
cancer.Added to this stress is the cost of
the treatment.In the end an empathetic
nursing team will work under stressful
condition to ensure that patients are
compassionately and effectively cared for.