Medicine

CONTRACEPTION, ABORTION, AND INFERTILITY

INFERTILITY

Prepared by Ass. Prof. N. Petrenko, MD, PhD

LEARNING OBJECTIVES

List common causes of infertility.

Discuss the psychologic impact of infertility.

Identify common diagnoses and treatments for infertility.

Examine the various ethical and legal considerations of assisted reproductive therapies for infertility.

KEY TERMS AND DEFINITIONS

assisted reproductive therapies (ARTs) Treatments for infertility, including in vitro fertilization procedures, embryo adoption, embryo hosting, and therapeutic insemination

basal body temperature (BBT) Lowest body temperature of a healthy person taken immediately after awakening and before getting out of bed

induced abortion Intentionally produced termination of pregnancy

in vitro fertilization Fertilization in a culture dish or test tube

infertility Decreased capacity to conceive

rhythm method Contraceptive method in which a woman abstains from sexual intercourse during the ovulatory phase of her menstrual cycle; calendar method semen analysis Examination of semen specimen to determine liquefaction, volume, pH, sperm density, and normal morphology

sterilization Process or act that renders a person unable to produce children

therapeutic donor insemination (TDI) Introduction of donor semen by instrument injection into thevagina or uterus for impregnation

vacuum aspiration Uterine aspiration method of early abortion

The reproductive spectrum is the focus of this chapter, covering voluntary control of fertility, interruption of pregnancy, and impaired fertility. The nursing role in the care of women varies, depending on whether management of these fertility-related concerns is associated with assessment of needs, investigation of problems, or implementation of interventions.

INFERTILITY

the inability to conceive following unprotected sexual intercourse year (age < 35) or 6 months (age >35)

Infertility is a serious medical concern that affects quality of life and is a problem for 10% to 15% of reproductive-age couples (American Society for Reproductive Medicine [ASRM], 1999; G. Stewart, 1998b). The term infertility implies subfertility, a prolonged time to conceive, as opposed to sterility, which means inability to conceive. Normally, a fertile couple has approximately a 20% chance of conception in each ovulatory cycle. Primary infertility applies to a woman who has never been pregnant; secondary infertility applies to a woman who has been pregnant in the past.

The prevalence of infertility is relatively stable among the overall population but increases with the age of the woman. For example, women older than age 40 have a 50% decreased fertility rate (G. Stewart, 1998b). Probable causes of infertility include the trend toward delaying pregnancy until later in life, when fertility decreases naturally and the prevalence of diseases such as endometriosis and ovulatory dysfunction increases.

There is some controversy regarding whether there has been an increase in male infertility, or whether male infertility is being more readily identified because of improvements in diagnosis. Diagnosis and treatment of infertility require considerable physical, emotional, and financial investment over an extended period. Men and women often perceive infertility differently, with women having more stress from tests and treatments, placing greater importance on having children, being more accepting of indicated treatments, and wanting children more than men (Stephen & Chandra, 1998).

Factors Associated with Infertility

Many factors, both male and female, contribute to normal fertility. A normally developed reproductive tract in both the male and female partner is essential. Normal functioning of an intact hypothalamic-pituitary-gonadal axis supports gametogenesis—the formation of sperm and ova. Although sperm remain viable in the female's reproductive tract for 48 hours or more, probably only a few retain fertilization potential for more than 24 hours. Ova remain viable for approximately 24 hours, but the optimal time for fertilization may be no more than 1 to 2 hours (Cunningham et al., 2001). Thus timing of intercourse is critical.

After fertilization the conceptus must travel down the patent uterine tube to the uterus and implant within 7 to 10 days in a hormone-prepared endometrium. The conceptus must develop normally, reach viability, and be born in good condition for extrauterine life.

An alteration in one or more of these structures, functions, or processes results in some degree of impaired fertility. In general, a female factor such as ovulatory dysfunction or a pelvic factor is responsible for infertility in approximately 50% of infertile couples (ASRM, 1999). A male factor (sperm and semen abnormalities) is responsible for infertility in approximately 35% of couples. Unexplained factors and causes (e.g., coital techniques) related to both partners are responsible for infertility in approximately 15% of couples (Session et al, 1998; Stenchever et al., 2001). Boxes 2 and 3 list factors affecting female and male infertility.

BOX 2

Factors Affecting Female Fertility

CONGENITAL OR DEVELOPMENTAL FACTORS

Abnormal external genitals

Absence of internal reproductive structures

OVARIAN FACTORS

Anovulation-primary

Pituitary or hypothalamic hormone disorder

Adrenal gland disorder

Congenital adrenal hyperplasia

Anovulation-secondary

Disruption of hypothalamic-pituitary-ovarian axis

Amenorrhea after discontinuing OCP

Early menopause

Increased prolactin levels

TUBAL/PERITONEAL FACTORS

Tubal motility reduced

Absence of fimbriated end of tube

Absence of a tube

Inflammation within the tube

Tubal adhesions

UTERINE FACTORS

Developmental anomalies

Endometrial and myometrial tumors

Asherman syndrome (uterine adhesions or scar tissue)

Fig CONGENITAL OR DEVELOPMENTAL ABNOMALIES

Fig Adhesions

Fig Adhesions and hydrosalpinx

Fig UTERINE FIBROID

Fig ENDOMETRIAL POLIP

Fig ENDOMETRIAL CANCER

Fig ENDOMETRIAL HYPERPLASY

Fig ENDOMETRIOSIS

Fig ASHERMAN SYNDROME

BOX 3

Factors Affecting Male Fertility

STRUCTURAL OR HORMONAL DISORDERS

Undescended testes

Hypospadias

Varicocele

Low testosterone levels

Testicular damage caused by mumps

OTHER FACTORS

Endocrine disorders

Genetic disorders

Psychologic disorders

Sexually transmitted infections

Exposure to workplace hazards such as radiation or

toxic substances

Exposure of scrotum to high temperatures

SUBSTANCE ABUSE

Changes in sperm (Smoking, heroin, marijuana, amyl nitrate, butyl nitrate, ethyl chloride, methaqualone; Monoamine oxidase )

Decrease in sperm (Hypopituitarism, Debilitating or chronic disease, Trauma, Gonadotropic inadequacy)

Decrease in libido (Heroin, methadone, selective serotonin reuptake inhibitors, and barbiturates)

Impotence (Alcohol, Antihypertensive medications)

OBSTRUCTIVE LESIONS OF THE EPIDIDYMIS AND VAS DEFERENS

NUTRITIONAL DEFICIENCIES

FIG. ANDESCENDENS TESTES

FIG. HYPOSPADIAS

FIG. VARICOCELE

CARE MANAGEMENT

Assessment and Nursing Diagnoses

The nurse assists in the assessment by obtaining data relevant to fertility through interview and physical examination. The database must include information to determine whether infertility is primary or secondary. Religious, cultural, and ethnic data are noted because they may place restrictions on tests and treatments.

Some of the data needed to investigate impaired fertility are of a sensitive, personal nature. Obtaining these data may be viewed as an invasion of privacy. The tests and examinations are occasionally painful and intrusive and can take the romance out of lovemaking. A high level of motivation is needed to endure the investigation.

Because multiple factors involving both partners are common, the investigation of impaired fertility is conducted systematically and simultaneously for both male and female partners. Both partners must be interested in the solution to the problem. The medical investigation requires time (3 to 4 months) and considerable financial expense, and it causes emotional distress and strain on the couple's interpersonal relationship (Angard, 2000).

Assessment of female infertility

Investigation of impaired fertility begins for the woman with a complete history and physical examination. The history explores the duration of infertility and past obstetric events and contains a detailed sexual history. Medical and surgical conditions are evaluated. Exposure to reproductive hazards in the home (e.g., mutagens such as plastic-vinyl chlorides, teratogens such as alcohol, and emotional stresses) and workplace are explored.

A complete general physical examination is followed by a specific assessment of the reproductive tract. Evidence of endocrine system abnormalities is sought. Inadequate development of secondary sex characteristics (e.g., inappropriate distribution of body fat and hair) may point to problems with the hypothalamic-pituitary-ovarian axis or genetic aberrations (e.g., polycystic ovarian syndrome, Turner syndrome).

A woman may have an abnormal uterus and tubes as a result of exposure to diethylstilbestrol (DES) in utero. Evidence of past infection of the genitourinary system is sought. Bimanual examination of internal organs may reveal lack of mobility of the uterus or abnormal contours of the uterus and adnexa. Data from routine urine and blood tests are obtained along with other diagnostic tests.

Diagnosis. The basic infertility survey of the woman involves evaluation of the cervix, uterus, tubes, and peritoneum (Figs. 9, 10, and 6-11); detection of ovulation; assessment of immunologic compatibility; and evaluation of psychogenic factors (Angard, 1999). The nurse can alleviate some of the anxiety associated with diagnostic testing by explaining to patients the timing and rationale for each test (Table 3). Test findings that are favorable to fertility are summarized in Box 4.

HSGHYDR7

Fig. 9 Hysterosalpingography. Note contrast medium flows through intrauterine cannula and out through the uterine tubes.

Fig. 10 Laparoscopy.

Fig. 11 Vaginal ultrasonography. Major scanning planes of transducer. H, Horizontal; V, vertical.

Table 3 Tests for Impaired Fertility

TEST/EXAMINATION	TIMING/(MENSTRUAL CYCLE DAYS)	RATIONALE
Hysterosalpingogram	7 to 10	Late follicular, early proliferative phase; will not disrupt a fertilized ovum; may open uterine tubes before time of ovulation
Postcoital test	1 to 2 days before ovulation	Ovulatory late proliferative phase; look for normal motile sperm in cervical mucus
Sperm immobilization antigen-antibody reaction	Variable, ovulation	Immunologic test to determine sperm and cervical mucus interaction
Assessment of cervical mucus	Variable, ovulation	Cervical mucus should have low viscosity, high spinnbarkeit
Ultrasound diagnosis of follicular collapse	Ovulation	Collapsed follicle is seen after ovulation
Serum assay of plasma progesterone	20 to 25	Midluteal midsecretory phase; check adequacy of corpus luteal production of progesterone
Basal body temperature	Chart entire cycle	Elevation occurs in response to progesterone, documents ovulation
Endometrial biopsy	26 to 27	Late luteal, late secretory phase; check endometrial response to progesterone and adequacy of luteal phase
Sperm penetration assay	After 2 days but no more than 1 week of abstinence	Evaluation of ability of sperm to penetrate an egg

BOX 4 Summary of Findings Favorable to Fertility

1. Follicular development, ovulation, and luteal development are supportive of pregnancy:

a. Basal body temperature (presumptive evidence of ovulatory cycles) is biphasic, with temperature elevation that persists for 12 to 14 days before menstruation

b. Cervical mucus characteristics change appropriately during phases of menstrual cycle

c. Laparoscopic visualization of pelvic organs verifies follicular and luteal development

2. The luteal phase is supportive of pregnancy:

a. Levels of plasma progesterone are adequate

b. Findings from endometrial biopsy samples are consistent with day of cycle

3. Cervical factors are receptive to sperm during expected
time of ovulation:

a. Cervical os is open

b. Cervical mucus is clear, watery, abundant, and slippery and demonstrates good spinnbarkeit and ar borization (fern pattern)

c. Cervical examination does not reveal lesions or infections

d. Postcoital test findings are satisfactory (adequate number of live, motile, normal sperm present in cervical mucus)

e. No immunity to sperm demonstrated

4. The uterus and uterine tubes are supportive of pregnancy:

a. Uterine and tubal patency are documented by

(1)Spillage of dye into peritoneal cavity

(2)Outlines of uterine and tubal cavities of adequate size and shape, with no abnormalities

b. Laparoscopic examination verifies normal development of internal genitals and absence of adhesions, infections, endometriosis, and other lesions

5. The male partner's reproductive structures are normal:

a. No evidence of developmental anomalies of penis, testicular atrophy, or varicocele (varicose veins on the spermatic vein in the groin)

b. No evidence of infection in prostate, seminal vesicles, and urethra

c. Testes are more than 4 cm in largest diameter

6. Semen is supportive of pregnancy:

a. Sperm (number per milliliter) are adequate in ejaculate

b. Most sperm show normal morphology

c. Most sperm are motile, forward moving

d. No autoimmunity exists

e. Seminal fluid is normal

Assessment of male infertility

The systematic investigation of infertility in the male patient begins with a thorough history and physical examination. Assessment of the male patient starts with noninvasive tests.

Semen analysis. The basic test for male infertility is the semen analysis. A complete semen analysis, study of the effects of cervical mucus on sperm forward motility and survival, and evaluation of the sperm's ability to penetrate an ovum provide basic information. Sperm counts vary from day to day and are dependent on emotional and physical status and sexual activity. Therefore a single analysis may be inconclusive (Hargreave & Ghosh, 1998). Usually, several specimens taken at monthly intervals are evaluated (Trantham, 1996).

Semen is collected by ejaculation into a clean container or a plastic sheath that does not contain a spermicidal agent. The specimen is usually collected by masturbation following 2 to 5 days of abstinence from ejaculation. The semen is taken to the laboratory in a sealed container within 2 hours of ejaculation. Exposure to excessive heat or cold is avoided. Normal values for semen characteristics are given in Box 5.

BOX 5Semen Analysis

Liquefaction usually complete within 10 to 20 minutes Semen volume 2 to 5 ml (range of 1 to 7 ml) Semen pH 7.2 to 7.8 Sperm density 20 to 200 million cells/ml Normal morphology, > 60% normal oval Motility (important consideration in sperm evaluation), percentage of forward-moving sperm estimated with respect to abnormally motile and nonmotile sperm > 50%

Ovum penetration test (may be done if further evaluation necessary)

Note: These values are not absolute, only relative to final evaluation of the couple as a single reproductive unit.

Hormone analyses are done for testosterone, gonadotropin, FSH, and LH. The sperm penetration assay may be used to evaluate the ability of sperm to penetrate an egg. Because human oocytes are not readily available, hamster eggs have been used as a substitute to evaluate sperm penetration abilities (no actual fertilization occurs) (Hargreave & Ghosh, 1998). Testicular biopsy may be warranted.

Assessment of the couple

Postcoital test. The postcoital test (PCT), also called the Sims-Huhner test, is one method used to test for adequacy of coital technique, cervical mucus, sperm, and degree of sperm penetration through cervical mucus. The test is performed within several hours after ejaculation of semen into the vagina. A specimen of cervical mucus is obtained from the cervical os and examined under a microscope. The quality of mucus and the number of forward-moving sperm are noted. A PCT with good mucus and motile sperm is associated with fertility (Hargreave & Ghosh, 1998).

Intercourse is synchronized with the expected time of ovulation (as determined from evaluation of BBT, cervical mucus changes, and usual length of menstrual cycle or use of an LH detection kit to determine LH surge). It is performed only in the absence of vaginal infection. Couples may experience some difficulty abstaining from intercourse for 2 to 4 days before expected ovulation and then having intercourse with ejaculation on schedule. Sex on demand may strain the couple's interpersonal relationship. A problem may arise if the expected day of ovulation occurs when facilities or the physician is unavailable (e.g., over a weekend or holiday).

Examples of nursing diagnoses related to impaired fertility include the following:

• Anxiety related to

-unknown outcome of diagnostic workup

• Disturbed body image or situational low self-esteem related to

-impaired fertility

• Risk for ineffective individual/family coping related to

- methods used in the investigation of impaired fertility

- alternatives to therapy: child-free living or adoption

• Interrupted family processes related to

-unmet expectations for pregnancy

• Acute pain related to

-effects of diagnostic tests (or surgery)

• Ineffective sexuality patterns related to

-loss of libido secondary to medically imposed restrictions

• Deficient knowledge related to

- preconception risk factors

- factors surrounding ovulation

- factors surrounding fertility

Expected Outcomes of Care

The expected outcomes are phrased in patient-centered terms and may include that the couple will do the following:

• Verbalize understanding of the anatomy and physiology of the reproductive system.

• Verbalize understanding of treatment for any abnormalities identified through various tests and examinations (e.g., infections, blocked uterine tubes, sperm allergy, varicocele) and be able to make an informed decision about treatment.

• Verbalize understanding of their potential to conceive.

• Resolve guilt feelings and not need to focus blame.

• Conceive or, failing to conceive, decide on an alternative acceptable to both of them (e.g., child-free living, adoption).

Plan of Care and Interventions

Psychosocial

Within the United States, feelings connected to impaired fertility are numerous and complex. The origin of some of these feelings are myths, superstitions, and misinformation about the causes of infertility. Other feelings arise from the need to undergo many tests and examinations and from being different from others.

Infertility is recognized as a major life stressor that can affect self-esteem; relations with the spouse, family, and friends; and careers. Couples often need assistance in separating their concepts of success and failure related to treatment for infertility from personal success and failure. Recognizing the significance of infertility as a loss and resolving these feelings are crucial to putting infertility into perspective, even if treatment is successful (Boxer, 1996).

Psychologic responses to a diagnosis of infertility may tax a couple's giving and receiving of physical and sexual closeness. The prescriptions and proscriptions for achieving conception may add tension to a couple's sexual functioning. Couples may report decreased desire for intercourse, orgasmic dysfunction, or midcycle erectile disorders.

To be able to deal comfortably with a couple's sexuality, nurses must be comfortable with their own sexuality so that they can better help couples understand why the private act of lovemaking must be shared with health care professionals. Nurses need up-to-date factual knowledge about human sexual practices and must be (1) able to accept the preferences and activities of others without being judgmental, (2) skilled in interviewing and in therapeutic use of self, (3) sensitive to the nonverbal cues of others, and (4) knowledgeable regarding each couple's sociocultural and religious tenets (Johnson, 1996).

The support systems of the couple with impaired fertility must be explored. This exploration should include persons available to assist, their relationship to the couple, their ages, their availability, and the cultural or religious support that is available.

If the couple conceives, nurses need to be aware that the concerns and problems of the previously infertile couple may not be over. Many couples are overjoyed with the pregnancy; however, some are not. Some couples rearrange their lives, sense of self, and personal goals within their acceptance of their infertile state. The couple may feel that those who worked with them to identify and treat impaired fertility expect them to be happy with the pregnancy. The couple may be shocked to find that they themselves feel resentment because the pregnancy, once a cherished dream, now necessitates another change in goals, aspirations, and identities. The normal ambivalence toward pregnancy may be perceived as reneging on the original choice to become parents. The couple might choose to abort the pregnancy at this time. Other couples worry about miscarriage. If the couple wishes to continue with the pregnancy, they will need the care other expectant couples need. A history of impaired fertility is considered to be a risk factor for pregnancy.

If the couple does not conceive, they are assessed regarding their desire to be referred for help with adoption, therapeutic intrauterine insemination, other reproductive alternatives, or choosing a child-free state. The couple may find a list of agencies, support groups, and other resources in their community helpful (see Resources at end of chapter).

Nonmedical

Simple changes in lifestyle may be effective in the treatment of subfertile men. Only water-soluble lubricants should be used during intercourse because many commonly used lubricants contain spermicides or have spermicidal properties. High scrotal temperatures may be caused by daily hot tub bathing or saunas in which the testes are kept at temperatures too high for efficient spermatogenesis.

Treatment is available for women who have immunologic reactions to sperm. The use of condoms during genital intercourse for 6 to 12 months will reduce female antibody production in most women who have elevated antisperm antibody titers. After the serum reaction subsides, condoms are used at all times except at the expected time of ovulation. Approximately one third of couples with this problem conceive by following this course of action.

Changes in nutrition and habits may increase fertility for both men and women. For example, a well-balanced diet, exercise, decreased alcohol intake, not smoking or abusing drugs, and stress management may be effective.

Medical

Pharmacologic therapy for female infertility is often directed at treating ovulatory dysfunction either by stimulating ovulation or by enhancing ovulation so that more oocytes mature. These medications include clomiphene citrate, human menopausal gonadotropin (HMG), FSH, recombinant FSH, and human chorionic gonadotropin. Gonadotropin-releasing hormone (GnRH) agonists, progesterone, and bromocriptine are also used (Angard, 1999; Leibowitz & Hoffman, 2000). Table 4 describes common medications used for treating infertility. Thyroid-stimulating hormone (Synthroid) is indicated if the woman has hypothyroidism. Combined oral contraceptives, GnRH agonists, or danazol may be used to treat en-dometriosis (Session et al., 1998).

Table 4 Medications Used in the Treatment of Infertility

DRUG	INDICATION	MECHANISM OF ACTION	DOSE	SIDE EFFECTS
Clomiphene citrate (Clomid, Serophene)	Ovulation induction, treatment of luteal-phase inadequacy	Thought to bind to estrogen receptors in the pituitary, blocking them from detecting estrogen	Tablets, starting with 50 mg/day for 5 days, may increase to 200 mg/day	Causes hypothalamus to release more GnRH, stimulating release of FSH and LH
Human menopausal gonadotropins (Pergonal)	Ovulation induction	Pergonal, LH, and FSH in 1:1 ratio, direct stimulation of ovarian follicle	Intramuscular injections, dosage regimen variable	Ovarian enlargement, ovarian hyperstimulation, local irritation at injection site, multifetal gestations
Purified FSH (Metrodin)	Treatment of polycystic ovarian disease	Direct action on ovarian follicle	Intramuscular injections, dosage regimen variable	Ovarian enlargement, ovarian hyperstimulation, local irritation at injection site multifetal gestations
Human chorionic gonadotropin (hCG) (Profasi)	Ovulation induction	Direct action on ovarian follicle to stimulate meiosis and rupture of the follicle	2000-10,000 units intramuscularly	Local irritation at injection site
Danazol (Danocrine)	Treatment of endometriosis	Combination of estrogen and androgen suppresses ovarian activity, eliminating stimulation to endometrial glands and stroma, with resultant shrinkage and disappearance	100-800 mg/day for 6 mo	Mild hirsutism, acne, edema and weight gain, elevation of liver enzyme levels
GnRH agonists (Synarel, Lupron, Zoladex)	Treatment of endometriosis, uterine fibroids	Desensitization and downward regulation of GnRH receptors of pituitary. resulting in suppression of LH, FSH, and ovarian function	Synarel, 200 yitg intranasally twice daily for 6 mo; Lupron, intramuscularly 375 mg every 28 days for 6 mo; Lupron, subcutaneously 0.1 mg daily for 6 mo	Synarel, nasal irritation, nosebleeds; Synarel and Lupron, hot flashes, vaginal dryness, myalgia and arthralgia, headaches, mild bone loss (usually reversible within 12-18 mo after treatment)
Progesterone(progesterone in oil, Progestoral)	Treatment of luteal-phase inadequacy	Direct stimulation of endometrium	Vaginal suppositories, 25-50 mg twice daily or 50 mg every night; rectal suppositories, 12.25 mg every 12 hr; progesterone capsules, 100 mg by mouth three times daily	Breast tenderness, local irritation, headaches

Adapted from Fogel, C, & Woods, N. (Eds.) (1995). Women's health care. Thousand Oaks, CA: Sage. FSH, Follicle-stimulating hormone; GnRH, gonadotropin-releasing hormone; LH, luteinizing hormone.

Drug therapy may be indicated for male infertility. Problems with the thyroid or adrenal glands are corrected with appropriate medications. Infections are identified and treated promptly with antimicrobials. FSH, HMG, and clomiphene may be used to stimulate spermatogenesis in males with hypogonadism (Leibowitz & Hoffman, 2000).

The primary care provider is responsible for informing patients fully about the prescribed medications. However, the nurse must be ready to answer patients' questions and to confirm their understanding of the drug, its administration, potential side effects, and expected outcomes. Because information varies with each drug, the nurse needs to consult the medication package inserts, pharmacology references, physician, and pharmacist as necessary.

Surgical

A number of surgical procedures can be used to treat problems causing female infertility. Ovarian tumors must be excised. When possible, functional ovarian tissue is left intact. Scar tissue adhesions caused by chronic infections may cover much or all of the ovary. These adhesions usually necessitate surgery to free and expose the ovary so that ovulation can occur.

Hysterosalpingography is useful for identification of tubal obstruction and also for the release of blockage (see Fig. 9). During laparoscopy, delicate adhesions may be divided and removed and endometrial implants may be destroyed by electrocoagulation or laser (see Fig. 6-10). Laparotomy and even microsurgery may be required to do extensive repair of the damaged tube. Prognosis depends on the degree to which tubal patency and function can be restored.

Surgical removal of tumors or fibroids involving the endometrium or uterus often improves the woman's chance of conceiving and maintaining the pregnancy to viability. Surgical treatment of uterine tumors or maldevelopment that results in successful pregnancy usually requires birth by cesarean surgery near term gestation to prevent uterine rupture as a result of weakness of the area of surgical healing.

Surgical procedures may also be used for problems causing male infertility. Surgical repair of varicocele has been relatively successful in increasing sperm counts but not fertility rates.

Reproductive alternatives

Assisted reproductive therapies. There have been remarkable developments in reproductive medicine. Assisted reproductive therapies (ARTs) have created ethical and legal issues (Box 6). The lack of information or misleading information about success rates and the risks and benefits of treatment alternatives prevents couples from making informed decisions. Nurses can provide in formation so that couples have an accurate understanding of their chances for a successful pregnancy and live birth. Some of the ARTs for treatment of infertility include in vitro fertilization procedures including in vitro fertilization-embryo transfer (IVF-ET), gamete intrafal-lopian transfer (GIFT) (Fig. 12), zygote intrafallopian transfer (ZIFT), ovum transfer (oocyte donation), embryo adoption, embryo hosting, surrogate mothering, therapeutic donor insemination (TDI), intracytoplasmic sperm injection, and assisted hatching. Table 5 describes these procedures and the possible indications for the ARTs.

insemination

ivf_lab

BOX 6 Issues to Be Addressed by Infertile Couples Before Treatment

Risks of multiple gestation

Possible need for multifetal reduction

Possible need for donor oocytes, sperm, or embryos or gestational carrier (surrogate mother)

Freezing embryos for later use

Possible risks of long-term effects of medications and treatment on women, children, and families

LEGAL TiP Cryopreservation of Human Embryos

Couples who have excess embryos frozen for later transfer must be fully informed before consenting to the procedure, to make decisions regarding the disposal of embryos in the event of (1) death, (2) divorce, or (3) the decision that the couple no longer wants the embryos at a later time.

Fig. 12 Gamete intrafallopian transfer (GIFT). A, Through laparoscopy, a ripe follicle is located and fluid containing the egg is removed. B, The sperm and egg are placed separately in the uterine tube, where fertilization occurs.

TABLE 5 Assisted Reproductive Therapies (ARTs)

PROCEDURE	DEFINITION	INDICATIONS
In vitro fertilization - embryo transfer (IVF-ET)	A woman's eggs are collected from her ovaries, fertilized in the laboratory with sperm, and transferred to her uterus after normal embryo development has occurred	Tubal disease or blockage; severe male infertility; endometriosis; unexplained infertility; cervical factor; immunologic infertility
Gamete intrafallopian transfer (GIFT)	Oocytes are retrieved from the ovary, placed in a catheter with washed motile sperm, and immediately transferred into the fimbriated end of the uterine tube. Fertilization occurs in the uterine tube	Same as for IVF-ET, except there must be normal tubal anatomy, patency, and absence of previous tubal disease in at least one uterine tube
IVF-ET and GIFT with donor sperm	This process is the same as described above except in cases where the male partner's fertility is severely compromised and donor sperm can be used; if donor sperm are used, the woman must have indications for IVF-ET and GIFT.	Severe male infertility; azoospermia; indications for IVF-ET or GIFT
Zygote intrafallopian transfer (ZIFT)	This process is similar to IVF-ET; after in vitro fertilization the ova are placed in one uterine tube during the zygote stage.	Same as for GIFT
Donor oocyte	Eggs are donated by an IVF procedure, and the donated eggs are inseminated. The embryos are transferred into the recipient's uterus, which is hormonally prepared with estrogen/progesterone therapy.	Early menopause; surgical removal of ovaries; congenitally absent ovaries; autosomal or sex-linked disorders; lack of fertilization in repeated IVF attempts because of subtle oocyte abnormalities or defects in oocyte/spermatozoa interaction
Gestational carrier (embryo host); surrogate mother	A donated embryo is transferred to the uterus of an infertile woman at the appropriate time (normal or induced) of the menstrual cycle	Infertility not resolved by less aggressive forms of therapy; absence of ovaries; male partner is azoospermic or is severely compromised
Donor embryo (embryo adoption)	A couple undertakes an IVF cycle and the embryo(s) is transferred to another woman's uterus (the carrier) who has contracted with the couple to carry the baby to term. The carrier has no genetic investment in the child. Surrogate motherhood is a process by which a woman is inseminated with semen from the infertile woman's partner and then carries the baby until birth.	Congenital absence or surgical removal of uterus; a reproductively impaired uterus. myomas, uterine adhesions, or other congenital abnormalities; a medical condition that might be life-threatening during pregnancy, such as diabetes, immunologic problems, or severe heart, kidney, or liver disease
Therapeutic donor insemination (TDI)	Donor sperm are used to inseminate the female partner.	Male partner is azoospermic or has a very low sperm count; couple has a genetic defect; male partner has antisperm antibodies
Intracytoplasmic sperm injection (ICSI)	Selection of one sperm cell that is injected directly into the egg to achieve fertilization. Used with IVF-ET.	Same as TDI
Assisted hatching	The zona pellucida is penetrated chemically or manually to create an opening for the dividing embryo to hatch and implant into uterine wall	Recurrent miscarriages; to improve implantation rate in women with previously unsuccessful IVF attempts; advanced age

Data from Angard, N. (1999). Diagnosis infertility. AWHONN Lifelines, 3(3), 22-29; Stenchever, M. et al. (2001). Comprehensive gynecology (4th ed.). St. Louis: Mosby; Seibel, M. (1997). Infertility: A comprehensive text (2nd ed). Stamford, CT: Appleton & Lange; and Van Voorhis, B. et al. (1998). Cost effective treatment of the infertile couple, fertil Steril, 70(6), 995-1005.

Complications. Other than the established risks associated with laparoscopy and general anesthesia, few risks are associated with IVF-ET, GIFT, and ZIFT. The more common transvagmal needle aspiration requires only local or intravenous analgesia. Congenital anomalies occur no more frequently than among naturally conceived embryos. Ectopic pregnancies do occur more often, however, and these carry a significant maternal risk. There is no increase in maternal or perinatal complications with TDI; the same frequencies of anomalies (approximately 5%) and obstetric complications (between 5% and 10%) that accompany natural insemination (through sexual intercourse) apply also to TDI.

Preimplantation genetic diagnosis. Preimplantation genetic diagnosis (PGD) or testing (PGT) is a form of early genetic testing designed to eliminate embryos with serious genetic defects before implantation through one of the ARTs and to prevent later termination of the pregnancy for genetic reasons (Fasouliotis & Schenker, 1999). There are more than 20 centers worldwide where PGD is being used clinically. Experts caution that use of PGD could lead to "new" eugenics (Draper & Chadwick, 1999; King, 1999). Couples need to be counseled about their options and choices, as well as the implications of their choices, when genetic analysis is considered (Jones, 2000).

Adoption. Couples may choose to build their family by adopting children who are not their own biologically. However, with increased availability of birth control and abortion and increasing numbers of single mothers keeping their babies, the adoption of Caucasian infants is extremely limited. Minority infants, infants with special needs, older children, and foreign adoptions are other options.

Couples who decide to adopt a child have decided that being a parent and having a child is more important than the actual process of birthing the child. The birth process is a small aspect of having a baby and becoming a parent. So much emphasis is placed on being pregnant and having a child composed of one's own genetic makeup that the focus of the reason to have a child becomes cloudy. The question to be answered by couples who are considering adoption is, "What is important to you – that you become parents or go through the experience of pregnancy and birth?"

Evaluation

Evaluation of the effectiveness of care of the couple experiencing impaired fertility is based on the previously stated outcomes (see Plan of Care).

PLAN OF CARE. Infertility

NURSING DIAGNOSIS Deficient knowledge related to the reproductive process with regard to conception as evidenced by patient questions

Expected Outcome Patient and partner will verbalize understanding of the components of the reproductive process, common problems leading to infertility, usual infertility testing, and the importance of completing testing in a timely manner.

Nursing Interventions/Rationales

Assess patient's current level of understanding of the factors promoting conception to identify gaps or misconceptions in knowledge base.

Provide information in a supportive manner regarding factors promoting conception including common factors leading to infertility of either partner to raise patient's awareness and promote trust in caregiver.

Identify and describe the basic infertility tests and the rationale for precise scheduling to enhance completion of the diagnostic phase of the infertility workup.

NURSING DIAGNOSIS Risk for ineffective individual/family coping related to inability to conceive as evidenced by patient and partner statements

Expected Outcome Patient and partner will identify situational stressors and positive coping methods to deal with testing and unknown outcomes.

Nursing Interventions/Rationales

Provide opportunities through therapeutic communication to discuss feelings and concerns to identify common feelings and perceived stressors.

Evaluate couple's support system, including support of each other during this process, to identify any barriers to effective coping.

Identify support groups and refer as needed to enhance coping by sharing experiences with other couples experiencing similar problems.

KEY POINTS

A variety of contraceptive methods are available with various effectiveness rates, advantages, and disadvantages.

Nurses need to help couples choose the contraceptive method or methods best suited to them.

Effective contraceptives are available through both prescription and nonprescription sources.

A variety of techniques are available to enhance the effectiveness of periodic abstinence in motivated couples who prefer this natural method.

Hormonal contraception includes both precoital and postcoital prevention through various modalities and requires thorough patient education.

The most widely used emergency contraceptive method is ingestion of large doses of estrogen and progestin oral contraceptive pills taken in two doses, 12 hours apart.

The barrier methods of diaphragm and cervical cap provide safe and effective contraception for women or couples motivated to use them consistently and correctly.

Proper use of latex condoms provides protection against STIs.

Tubal ligations and vasectomies are permanent sterilization methods used by increasing numbers of women and men.

Elective abortion performed in the first trimester is safer than an abortion performed in the second trimester.

The most common complications of elective abortion include infection, retained products of conception, and excessive vaginal bleeding.

Major psychologic sequelae of elective abortion are rare.

Infertility is the inability to conceive and carry a child to term gestation at a time the couple has chosen to do so.

Infertility affects between 10% and 15% of otherwise healthy adults. Infertility increases in women older than 40 years.

In the United States, 50% of infertility is related to female causes, 35% is related to male causes, and 15% is related to couple causes and unexplained causes.

Common etiologic factors of infertility include decreased sperm production, ovulation disorders, tubal occlusion, and endometriosis. Reproductive alternatives for family building include IVF-ET, GIFT, ZIFT, oocyte donation, embryo donation, TDI, surrogate motherhood, and adoption.

CRITICAL THINKING EXERCISES

1. Explore the options in your community for diagnosis, treatment alternatives, and support services for couples experiencing infertility. Discuss your findings in a clinical conference, including the ease or difficulty a couple would have in getting help with their problem.

2. Visit a clinic that provides family planning services in your area.

a. Are there differences in fee schedules for women with and without insurance? Are local, state, or federal funds available for these family planning services?

b. Are the hours of service sufficient to meet the needs of patients? How long are typical waits to be seen during a scheduled appointment?

c. What is the nurse's role in the clinic? What other health care professionals are present and what are their roles? Is there any collaboration among these care providers?

d. Make suggestions for changes in the way care is provided that increase efficacy and patient satisfaction.

3. You are working in a health department clinic. A 16-year-old, unmarried woman who has missed one menstrual period comes in requesting information about options for an unwanted pregnancy.

a. Examine your values about teenage pregnancy. Explore your beliefs about options for an unwanted pregnancy. How might these values and beliefs affect your ability to provide information about options in a nonjudgmental manner?

b. What patient information do you need to know before counseling a woman about her options?

c. What information is needed by the pregnant woman in making a decision about her unwanted pregnancy?

d. What are the laws in your state related to abortion, informed consent, and treatment of minors?

e. Select one option for this hypothetical patient and justify your choice.

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