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Chapter 19
Family Planning and Infertility
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
1
Contraceptives
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
2
Objectives
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Define key terms listed.
Identify factors that influence the woman’s
choice of contraceptive method.
Discuss five types of contraception.
Explain how the male condom should be
used to be most effective.
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
3
Objectives (cont.)


Describe a method of contraception that
reduces the risk of sexually transmitted
infections.
List advantages and disadvantages of five
types of contraception.
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
4
Family Planning

Choice involves
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Personal
Social
Economic
Religious
Cultural
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5
Reversible Contraception

Decisions on what to use should be
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
Voluntary
With full knowledge of
• Advantages and disadvantages
• Effectiveness
• Side effects
• Contraindications
• Long-term effects
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
6
Factors in Selecting
Contraception
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Cost of method
Effectiveness
Availability
Partner’s support
and willingness to
cooperate
Safety of method
Protection against
sexually transmitted
infections (STIs)
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Convenience
Desirability or
personal preference
Personal motivation
and compliance
Religious and moral
factors
Medical problems
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
7
Abstinence
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Acts as a contraceptive by eliminating the
possibility of sperm entering the woman’s
vagina
Completely effective in preventing pregnancy
Is a means of avoiding STIs
Rhythm method of contraception includes
abstinence during the point in her menstrual
cycle when she is most fertile
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
8
Fertility Awareness


The understanding that a woman is fertile at
ovulation
Time of ovulation can be confirmed by

Basal body temperature (BBT)
 Cervical mucus method (known as the Billings
method)
 Symptothermal method
 Chemical predictor test
 Rhythm methods (also called the calendar
method)
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
9
Mechanical Barrier Methods
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Chemicals or devices
Prevent transport of sperm to cervix or
implantation of fertilized ovum
Spermicides inserted at least 1 hour before
coitus

Usually ineffective if used alone; use with condom,
diaphragm, or cervical cap
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
10
Vaginal Spermicides
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Immobilize and destroy sperm
Neutralize vaginal secretions
Viruses and some other pathogens are not
susceptible to spermicides
Cannot be relied on to protect against STIs
Examples: creams, foams, film, suppositories
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
11
Spermicides
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Activate when exposed to body warmth in
vagina
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Short-acting
 Inactive within an hour after insertion
 A single application provides protection against
one ejaculation
 Can be messy, leak


Low-cost and safe
Failure rate is 6%
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
12
Male Condom
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Flexible sheath worn over erect penis
Inexpensive, accessible, effective means of
contraception
Reduces spread of STIs
Failure rate 3%; if used with spermicides,
failure rate 2% or less
Four basic features differ among condoms
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Material: latex or polyurethane
Shape: reservoir at tip
Lubricant: wet jelly or dry powder
Spermicides
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
13
Male Condom (cont.)
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Latex
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Prolonged storage in hot, humid climates or
contact with vaginal antifungal creams, suntan oil,
or oil-based lubricants such as petroleum jelly, will
cause the latex to break down and the condom will
be ineffective for birth control
Polyurethane

Less constricting fit, more resistant to deterioration
 May enhance sensitivity
 Compatible with oil-based lubricants
 Protect against STIs
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
14
Female Condom
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A thick lubricated polyurethane sheath, 7
inches long with flexible ring at each end
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Inner ring serves as means of insertion
Covers cervix like diaphragm
Second ring remains outside vagina
Can insert up to 8 hours before intercourse
OTC and single use only
Do not use with male condom
Failure rate is 21%
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
15
Diaphragm
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Latex or rubber cup surrounded by spring or
coil that fits snugly over cervix
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Can put spermicidal cream or gel in dome and
around rim
Prevents passage of sperm into cervix
Requires fitting by health care provider

Size should be rechecked after each term birth or
if woman gains or loses 4.5 kg (10 lbs)
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
16
Diaphragm (cont.)
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Holds spermicide in place against cervix for
the 6 hours it takes to destroy the sperm
Can be inserted up to 4 hours before
intercourse
Spermicide must be inserted into vagina each
time intercourse is repeated
Do not leave in place longer than 24 hours
Cannot be relied on to protect against STIs
Failure rate is 6%
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
17
Cervical Cap
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Cup-shaped device, smaller than diaphragm
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Once placed over cervix, remains in place by
suction
Not all women can be fitted for this
Can remain in place 24 to 48 hours
Fitting should be checked yearly, after
childbirth, and after vaginal or uterine surgery
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
18
Intrauterine Device (IUD)
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Small, T-shaped, flexible device inserted by
health care provider
Provides continuous pregnancy prevention
Most often prescribed for women who have
had at least one term pregnancy
Not recommended for women with multiple
sexual partners
Does not protect against STIs
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
19
Contraindications for
IUD Insertion
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Liver disease
Copper allergy
Breast cancer
Immunodeficiency disorders
Immunosuppressive therapy
Uterine abnormalities
Pelvic infection or disorder
Undiagnosed vaginal bleeding
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
20
Hormonal Contraceptives
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Oral Contraceptives (OCs)
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Birth control pill
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Prevents pregnancy by suppressing ovulation
through combined actions of synthetic estrogen
and progestin
Thickens cervical mucus
Alters decidua of uterus, preventing implantation
Failure rate 1% if taken as directed
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
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“Minipill”
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Contains only progestin
Works in same way as regular pill but is less
effective in suppressing ovulation
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
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Side Effects of OCs
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Can range from nausea to breakthrough
bleeding to thrombus formation
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May be either estrogen- or progestin-related
Adolescents must have at least three
ovulatory cycles before starting OCs
After term delivery, OCs can be started about
4 weeks postpartum
OCs can decrease volume of breast milk, so
do not start until milk well-established
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
24
Warning Signs to Report
with OC Use
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Breast lump
Depression
Jaundice
Abdominal pain
Severe leg pain
Severe headaches
or dizziness
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Weakness or
numbness
Vision loss or
blurred vision
Speech problems
Chest pain, cough,
or shortness of
breath
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
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Contraindications to OCs
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Vascular pathologic
conditions
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Thromboembolism or
pulmonary embolism
Stroke,
atherosclerosis,
heart disease or
failure
Hypertension
Breast cancer within
5 years
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Diabetes with
neuropathy
Retinopathy, liver
disease
Smoking
Age older than 35
years
Pregnancy
Migraines with aura
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
26
Education About OCs
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Proper use can increase effectiveness
Combination OCs come in packets of 21 or
28 tablets
Important to take pill at same time every day
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Keeps blood hormone levels stable
Review what she should do if a pill is missed
Certain drugs, such as antibiotics, can
interfere with effectiveness of OC
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
27
Follow-up Care
for Women Taking OCs
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Yearly pelvic examination
Pap smear
Breast examination
Blood pressure measurement
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
28
Hormonal Skin Patch
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Applied to dry skin of buttock, abdomen,
upper arm, or torso on first day of menstrual
period
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Wear patch for 1 week and replace each week x
3; week 4 is patch-free
Advantages: consistent level of hormone in
blood, avoids liver metabolism
Not recommended for women weighing 90 kg
(198 lbs) or more
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
29
Vaginal Ring
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Flexible silicone ring inserted into vagina for 3
weeks, removed for 1 week to allow for
menstruation
Provides steady low-dose hormone
Leukorrhea and vaginal infections common
side effects
Fertility returns rapidly after ring discontinued
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
30
Implantable Contraceptives
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Implanon, single silicone rod that uses
etonogestrel
Inserted subdermally
Provides contraception for 3 years
Does not prevent STIs
Can be inserted or removed in outpatient
clinic under local anesthesia
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
31
Injectable Contraceptives
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Depo-medroxyprogesterone acetate (DMPA)
suspension (Depo-Provera)
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Single injection every 3 months
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Long-acting, injectable progestin
Alters cervical mucus so it is hostile to sperm
• Impairs ovulation and implantation
Contraceptive effect could last up to 1 year
Pregnancy test performed before first
injection
Side effects: menstrual spotting, headache,
weight gain; does not protect against STIs
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
32
Emergency Contraception
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Effective if started 24 to 72 hours after
unprotected intercourse
Take 1 pill, then another 12 hours later
Side effects include nausea, vomiting, breast
tenderness, and menstrual irregularities
Noncompliance with regimen is most
common cause of failure
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
33
Least Effective
Methods of Contraception
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34
Coitus Interruptus
(Withdrawal)
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Man withdraws penis from vagina before
ejaculation
Prevents large quantity of sperm from being
deposited into vagina
May misjudge timing and withdraw too late
Also, fluid that escapes from penis before
ejaculation also contains sperm
NOT A RELIABLE METHOD OF BIRTH
CONTROL
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
35
Postcoital Douche
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Sperm are known to appear in cervical mucus
within a few seconds after ejaculation
Sperm can reach site of fallopian tube within
a short time
Once sperm are in tube, pregnancy can result
and douching will not prevent this
NOT A RELIABLE METHOD OF BIRTH
CONTROL
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
36
Breastfeeding
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Inhibits ovulation because prolactin alters
ovarian response to hormones and return of
menses
Frequency, intensity, and duration of
breastfeeding may maintain anovulatory
status for 4 to 6 months; then prolactin
decreases and ovulation returns
Pregnancy can occur before menses return
NOT A RELIABLE METHOD OF BIRTH
CONTROL
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
37
Permanent Contraception
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Legal aspects
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Informed consent
• Should include risks, benefits, alternatives, and a
statement that procedure is permanent and may be
irreversible
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No absolute guarantee that the procedure will
prevent pregnancy in most procedures
 Some states require a 30-day waiting period
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
38
Male Sterilization
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Minor surgical procedure
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3-cm incision made and vas deferens is severed
and occluded
Takes approximately 6 weeks and up to 36
ejaculations to clear remaining sperm
On follow-up visits, man may be asked to
submit semen samples to assess sperm
count
Can be reversed in some cases
Vasectomy has no effect on sexual
performance
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
39
Female Sterilization
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Tubal ligation: surgical procedure
Transcervical occlusion: a coil is inserted into
each fallopian tube, leading to complete
occlusion within 3 months
Neither protects against STIs
Does not affect menstruation or sexual
performance
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
40
Nursing Responsibilities
Related to Sterilization
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Listen to patient’s concerns
Verify information regarding benefits, risks,
and alternatives
Provide emotional support
Discuss
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Preoperative and postoperative care
Signs and symptoms to report
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
41
Discussion Question 1

Does your state allow pharmacists to provide
women with Plan B without a prescription?
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42
Infertility Treatments
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43
Objectives
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Explain male sterilization.
Explain female sterilization.
Discuss the role of the nurse in caring for
patients with contraceptive or fertility
problems.
Describe a therapy to facilitate pregnancy.
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
44
Objectives (cont.)


Review factors that contribute to infertility.
Describe four types of treatment protocols in
the management of infertility.
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
45
Infertility and Therapies
to Facilitate Pregnancy
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46
Definitions of Fertility and
Infertility
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Fertility: the capacity to conceive or
reproduce
Infertility: the inability to conceive or
reproduce after 1 year of regular, unprotected
sexual intercourse; or the inability to conceive
at the time desired
Sterility: partner has irreversible factor that
prevents fertility
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
47
Infertility
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Primary
Secondary
Unsuccessful pregnancy
Single infertility
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48
Cultural and Religious
Considerations
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Fertility (or lack of) is strictly seen as a female
problem by some cultures
Stigma of infertility can lead to divorce or
rejection by family or society
Religious norms influence what tests or
treatments can be pursued
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
49
Factors in Fertility
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Coital frequency: 3 times
per week
Age: woman older than 35
years
Smoking: increases
peristalsis of fallopian
tubes
Exercise and weight loss
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Too much exercise—
menstrual irregularity
Excessive weight—
amenorrhea
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Diet: B12 deficiency
Stress: significant cause of
infertility
Medical conditions
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Pelvic adhesions, pelvic
inflammatory disease
Endocrine disorders
Use of drugs (prescription
or illicit)
Exposure to chemicals
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50
Infertility Management Program
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Contributing factors are discussed
Before treatment is initiated, diagnostic tests
may be performed
Tests may include tubal function, ovulation,
hormone levels, BBT, endometrial biopsy
Multidisciplinary team includes
endocrinologist, urologist, psychologist,
gynecologist, nurse, and the couple
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51
CAM Medical Therapy
for Infertility

Acupuncture thought to increase sperm
counts in the male
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
Ginseng and astragalus
Enhance assisted reproductive technology in
the female
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52
Male Infertility
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Defect in transport system of sperm
Defect in sperm production
Inability to deposit sperm into woman
Use of tobacco, alcohol, illicit drugs can also
contribute
Some prescription drugs can inhibit sperm
production, cause ejaculatory problems, or
lead to erectile dysfunction
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
53
Fertility Tests for Males
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Semen and sperm analysis
Transrectal ultrasound
Hormonal profile
Postejaculatory urinalysis to test for
retrograde ejaculation
Vasograph
Genetic testing
Postcoital sperm count
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
54
Treatment of Male Infertility
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Surgical intervention for varicocele
Antimicrobial therapy for genital infections or
trauma to reproductive tract
Medications and mechanical aids can be
used for erectile dysfunction
Instruct male to wear loose-fitting underwear;
avoid saunas, smoking, St. John’s wort,
anabolic steroids; and eat healthy diet
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
55
Treatment of Female Infertility

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Transcervical balloon tuboplasty to unblock
fallopian tubes
Laparoscopy or laparotomy
Laser to remove scar tissue
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56
Assisted Reproductive
Technology
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57
Legal and Ethical Factors
in Assisted Reproduction

Can be used in a variety of ways in addition
to helping infertile couples

Couples who want to avoid genetic anomalies
 Sperm or egg donors
 Surrogate parent (mother, father, or both)
 Homosexual couples
 Single parents


Cloning of a lost child may someday be
possible
What to do with frozen embryos
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58
Assisted Reproductive
Techniques (ART)

Examples include
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In vitro fertilization (IVF)
Gamete intrafallopian transfer (GIFT)
In vitro fertilization−embryo transfer (IVF-EF)
Each begins with ovulation induction to permit
retrieval of ova
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59
Ovulation Induction

Woman is given medications to induce
ovulation
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
Ovarian hyperstimulation syndrome is not
uncommon when ovarian enlargement and
follicular cysts are present
One of three medications



Selective estrogen receptor modulators
Aromatase inhibitors
Injectable gonadotropins
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60
Therapeutic Insemination

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Formerly known as artificial insemination
Instillation of ova or sperm into uterus to aid
conception
Intrauterine insemination can also be used
Donor sperm and ova may be frozen and
held for 6 months before use to reduce risk of
infections that may not have been detectable
at initial screening
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61
Role of the Nurse
in Contraception and Infertility


Assess contraceptive knowledge, attitudes
and plans for pregnancy, need for family
planning, and preferred methods
Nurse is an educator, advocate, and
counselor who offers the couple a sense of
control and acceptance
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
62
Discussion Question 2

What is the nurse’s role in caring for a couple
with infertility issues?
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63
Review Key Points
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64