Challenges and Management of Infertility, Including Assisted Reproductive Technologies

Challenges and Management of

Infertility, Including Assisted

Reproductive Technologies

Kit S. Devine, MSN, ARNP

IntroductionThe inability to create a desired pregnancy that culminates in the birth of a child is likely to create a life crisis for women and their partners. Women seeking fertility treatment look to nurses for care, counsel and health teaching.

Introduction (Continued)

• Primary infertility: The inability to conceive after 1 year of unprotected intercourse for a woman younger than 35, or after 6 months of unprotected intercourse for a woman 35 or older (Speroff & Fritz, 2005).

• Secondary infertility: The inability of a woman to conceive who previously was able to do so (Speroff & Fritz, 2005).

Introduction (Continued)

Infertility is more common in older women. However, increased age reduces the efficacy of treatment.

Prevalence and Overview of Treatments• The overall incidence of infertility has

remained relatively unchanged for the past 30 years (Speroff & Fritz, 2005).

• In 2002, about 2 percent of women of reproductive age had an infertility-related medical appointment within the previous year, and 10 percent had an infertility-related medical visit at some point in the past (Chandra et al., 2005).

Prevalence and Overview of Treatments (Continued)

Approximately half of all women who receive fertility care achieve conception

leading to a live birth (Speroff & Fritz, 2005).

Scope of the Problem

Types of ART cycles: United States, 2004 (Speroff & Fritz, 2005)

Factors Influencing the Use of Fertility Services• Increased education and career

opportunities for women • Increased number of providers and

centers offering fertility services• Increased public awareness of

infertility and treatment options

Causes of Infertility

• Discovering which cause of infertility affects a particular couple is the basis of fertility care.

• Causes are shared, almost equally, by men and women.

• Mixed-factor infertility involves multiple causes, with some belonging to the man and some to the woman.

Causes of Infertility (Continued)

Couples (Speroff & Fritz, 2005)

Causes of Infertility (Continued)

Women (Speroff & Fritz, 2005)

Evaluation of the WomanPrimary evaluation components:

– Male factor– Ovarian factor– Cervical factor– Tubal factor– Uterine factor

Physical Evaluation• Obtain a complete health history of

both partners• Assess the woman’s hormone

values• Perform a complete pelvic exam• Order the man’s semen analysis

Complete Pelvic Examination• Abnormalities and current

pathologies are ruled out.• Discovery of abnormalities

influence the management and efficacy of care.

• Transvaginal ultrasound (TVUS): Used to examine the uterus, endometrium, ovaries and tubes

Complete Pelvic Examination (Continued)

• Sonohysteroscopy: Used to identify polyps, fibroid tumors, cysts or other intrauterine masses

• Hysterosalpingogram: Used to evaluate the interior uterus and fallopian tubes

Complete Pelvic Examination

(Continued)

Endometrial cavity distended during saline hysterography

Image provided by author. Reprinted with permission. (Figure 3)

Complete Pelvic Examination (Continued)

• Tubal and peritoneal pathology are the primary problem for 30 percent to 35 percent of infertile couples (Miller et al., 1999).

• Providers should know the status of the fallopian tubes before any fertility treatment begins.

Evaluation of Ovulatory FunctionWomen can use simple, noninvasive techniques to predict ovulation:

– Daily basal body temperature– Ovulation predictor kits – Salivary predictor tests

Evaluation of Ovulatory Function (Continued)

• TVUS: Evaluates ovarian follicle development and quality of the endometrial lining

• Clomid Challenge Test (CCT): Assesses ovarian reserve in the older woman or the woman suspected of having early ovarian failure

Enlarged ovarian follicle filled with fluid and a mature ooctye

Mature oocyte

Anovulation and oligoovulation:– Among the most common causes of

infertility– More common in women who:

•Have extremes of body weight•Exercise excessively•Struggle with eating disorders

Ovarian Dysfunction and FailureSome women fail to ovulate because they have very few or no remaining oocytes.

– Before about age 40, this condition is classified as premature ovarian failure or premature menopause.

– Using a donated oocyte or embryo adoption are the only options for affected women who desire to become pregnant.

Endometriosis• Strongly associated with infertility• Affects 20 percent to 40 percent of

infertile women• Management methods include

surgery and medication

Recurrent Pregnancy Loss• Chromosomal abnormalities• Uterine malformations• Immunologic factors• Thrombophilias• Endocrine abnormalities• Infectious disease• Environmental contributors

Factors that Affect Fertility• Chronic stress related to fertility• Smoking and exposure to

secondhand smoke• Excessive alcohol intake• Illicit drug use• Extreme body mass index (BMI)• Eating disorders

Polycystic Ovarian Syndrome (PCOS)• Affects women with irregular

menses and an inability to maintain normal BMI

• Usually includes elevated levels of serum androgens, insulin resistance and chronic anovulation

PCOS (Continued)

Ovaries affected by PCOS

Surgical and Radiological Evaluation• Providers should evaluate pelvic

pain that is more than mild uterine cramping.

• TVUS can identify or rule out reasons for pelvic pain.

• Laparoscopy and hysteroscopy can evaluate and address conditions such as endometriosis, pelvic adhesions and tubal abnormalities.

Evaluation of the Male• Male factor contributes to

infertility in 50 percent of infertile couples (Trummer et al., 2000).

• Evaluation begins at the initial consultation with the couple.

Evaluation of the Male (Continued) • Physical examination

– Obesity– Hypothalamic or pituitary failure– Abnormalities of the testes, epididymis,

prostate or penis– Presence of vas deferens– Degrees of varicocele

• Semen analysis• Endocrine and chromosomal

assessment• Anatomical evaluation• Psychological factors

Fertility Treatment: Goals• To ensure patient safety• To help a couple experience a

healthy pregnancy and birth or an alternative way to build a family

• To use as little of a couple’s resources as necessary

Fertility Treatment: Options• Correct ovulatory dysfunction• Correct tubal or uterine

abnormalities• Overcome subfertile sperm

parameters• ART

Ovulation Induction: Clomiphene Citrate (Clomid, Serophene)• The “first line” of fertility therapy• Used to treat mildly disordered

ovulation and luteal-phase insufficiency

• Establish tubal patency and sperm adequacy before use.

Ovulation Induction: Clomiphene Citrate (Continued)

• In appropriately selected patients, 80 percent ovulate and 40 percent conceive with clomiphene (Imani, Eijkemans, te Velde, Habbema & Fauser, 1999).

• Cumulative conception rate is 60 percent to 75 percent (Dickey & Holtkamp, 1996).

Ovulation Induction: Clomiphene Citrate (Continued)

• Multiples rate is about 10 percent (Imani, Eijkemans, te Velde, Habbema & Fauser, 2002).

• After 6 months, women should move on to more aggressive therapy.

Ovulation Induction: Injectable Gonadotropins• Used:

– When women exhibit resistance to clomiphene

– When multiple oocytes are desirable to ovulate

– With IVF and creation of donor oocytes and embryos

– With ovulation induction (OI)

• Multiple rates as high as 40 percent (Jones, 2007).

Mature ovarian follicles from gonadotropin stimulation

Ovulation Induction: Injectable Gonadotropins (Continued)

Images provided by author. Reprinted with permission. (Figure 7)

Ovulation Induction: Pulsatile Gonadotropin-Releasing Hormone• Anovulation may be due to the failure

of the hypothalamus to provide sufficient stimulation to the pituitary gland.

• Gonadotropin-releasing hormone (GnRH) can be directly administered via a small medication pump to induce ovulation.

• The ideal patient is the hypogonadotropic woman.

Ovulation Induction: Pulsatile GnRH (Continued)

• Overall ovulation rates are between 50 percent and 80 percent. The chance of pregnancy is 10 percent to 30 percent per ovulatory cycle, depending on the couple’s other fertility factors (Gill et al., 2001).

• The risk of multiples is low. The risk of moderate or severe hyperstimulation is very low (<1 percent) (Gill et al., 2001).

Artificial Insemination• Used to treat:

– Male-factor infertility – Retrograde ejaculation– Neurologic impotence – Sexual dysfunction

• Sperm used for insemination may be the male partner’s or donated.

Artificial Insemination (Continued)

• Methods of insemination– Intracervical insemination (ICI) – Intrauterine insemination (IUI)

• Success rates vary from 6 percent to 24 percent per cycle (van der Westerlaken et al., 1998).

Assisted ReproductionAssisted hatching of the embryo

Assisted Reproduction (Continued)

Indications for ART:– Tubal disease– Male-factor infertility– Endometriosis– Premature ovarian failure– Polycystic ovarian syndrome– Immunologic infertility– Unexplained infertility

• IVF: Placing the gametes and subsequent embryo into the uterus

• ZIFT (zygote intrafallopian transfer): Placing the gametes and subsequent embryo into the fallopian tubes

• GIFT (gamete intrafallopian transfer): Placing the unfertilized oocyte and sperm into the fallopian tube

• Stimulation type, dosage and duration depends on patient characteristics, diagnoses and the fertility center.

• Monitoring is usually by serial TVUS, usually over four to five visits.

• Cleavage of the embryos and other subjective indicators of embryo health help the clinician decide timing and number of embryos to transfer.

• The usual timing of transfer of embryos is on day 3, 4 or 5 after retrieval.

Multicellular embryos

Assisted Reproduction: CryopreservationFreezing, thawing and using:

– Sperm– Embryos– Oocytes

Assisted Reproduction: Cryopreservation (Continued)

Expanded blastocysts

Assisted Reproduction: Cryopreservation (Continued)

Cryopreserved blastocysts

Images provided by author. Reprinted with permission. (Figure 11)-

Preimplantation Genetic Diagnosis (PGD)

• Used only with IVF• One or two cells removed from the

embryo and analyzed for defects before transfer to the uterus

PGD (Continued)

• May be helpful for:– Women older than 35 years– Couples who have experienced

recurrent pregnancy loss – Couples with one partner known to

carry a balanced chromosomal translocation

• Up to 85 percent accurate for detecting the most common chromosomal abnormalities (Knops, 2004)

Third-party Reproduction• Donor gametes • Donor embryos • Surrogacy

– Gestational carrier: Carries other people’s oocyte and sperm

– Traditional surrogate: Inseminated with the male partner’s sperm

Third-party Reproduction (Continued)

Fertilized oocyte

Image provided by author. Reprinted with permission. (Figure12)

ART Risks and Complications• Ovarian hyperstimulation

syndrome (OHHS)• Multiple gestation—More than 43

percent of the rise in multiple births in the U.S. is linked to ART, with 25 percent to 38 percent of treatments leading to multiple births (Jain et al., 2004).

ART Risks and Complications (Continued)

Triplet and higher-order deliveries: United States, 1996 to 2004 (NCHS, final natality data, 1996 to 2004)

Twin intrauterine pregnancy6 weeks 7 weeks

Images provided by author. Reprinted with permission. (Figure14)

Twin intrauterine pregnancy (Continued)

9 weeks 13 weeks

Images provided by author. Reprinted with permission. (Figure14)

Male-factor Infertility ART may help men with:

– Sperm counts between 1 and 10 million with poor motility and morphology scores

– Failed previous inseminations– Obstructive or nonobstructive

azoospermia where sperm can be successfully extracted from the epididymis or testes

Male-factor Infertility (Continued)

Intracytoplasmic sperm injection (ICSI)

Image provided by author. Reprinted with permission. (Figure15)

Advanced Reproductive AgePercentage of births by maternal age: United States, 2000 to 2004 average (NCHS, final natality data, 2000 to 2004)

Advanced Reproductive Age (Continued)

Risks– Pregnancy loss at all stages of

gestation– Down syndrome– Multiple births– Hypertension and gestational

diabetes– Low birthweight (LBW)– Difficult labor– Cesarean birth

Risks (Continued)

– Risks associated with older childbearing are manageable. Most women can expect positive outcomes (Carolan, 2003).

– Nurses should counsel women in their early 30s about fertility.

Multiple deliveries by maternal age: United States, 2002 to 2004 average (NCHS, final natality data, 2002 to 2004)

Adjustment to Pregnancy and Parenting• Women who conceive as a result

of ART: Increased risk for mood disorders during pregnancy and for early parenting difficulties (Fisher et al., 2005; Olshansky & Sereika, 2005)

• Women with multiple newborns: Increased risk for postpartum depression (Fisher & Stocky, 2003)

• Children born after ART: Increased risk of birth defects

Financial Counseling• Treatment can be expensive.• Providers should ensure that

clients understand all the options and costs.

Special Role of Nursing• To help reduce a woman’s anxiety,

increase her knowledge and validate the significance of her experience throughout evaluation and treatment

• To guide the woman through grief that follows unsuccessful treatment and help her determine when it is time to stop treatment (Clapp, 2004)

Nursing Strategies• Giving anticipatory guidance• Providing a quiet, private place for

consultation• Allowing adequate time for

questions and discussion• Giving patient-specific instructions• Giving therapeutic touch, when

appropriate

Nursing Strategies (Continued)

• Maintaining personal contact during and after treatment cycles

• Recognizing the need for grief work• Expressing positive and negative

feelings• Providing easy access to nursing care• Follow up to discuss options and

emotional status

Summary• Nurses practicing in women’s health

are likely to encounter women who need accurate and compassionate information about infertility and its treatment.

• Knowledge of infertility diagnoses and treatment is fundamental to creating best nursing interventions for these women and their partners.

Challenges and Management of Infertility, Including Assisted Reproductive Technologies

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