S.

n Time Specific content Teaching Evaluation

o objectives learning aids
1 30 Introduction: According to WHO, positive reproductive Lecture cum
sec health of a woman is a state of complete physical , mental & discussion
social well being & not merely absence of disease related to PPT, Pamphlets
reproductive system & function . It’s a serious medical
concern that affects quality of life & is a problem for a 10-15
% of reproductive age couples.

2 30 To define • Definition: Infertility is defined as the inability Lecture cum Define

sec infertility to conceive after one year of regular sexual discussion infertility
attempt without contraception when the couple PPT, Pamphlets
gets worried for a baby.

• Study based on an observation shows that,

 80 % of normal couple conceive within a year
 50 % of them within 3 months
 75 % of them within 6 months

3 30 To describe CLINICAL GROUPS OF INFERTILE COUPLE AS PER Lecture cum Describe

sec incidence rate ETIOLOGY: discussion incidence rate
of infertility • Male defect in 40% PPT of infertility
• Female defect in 50%
• Unexplained cause in 10%

4 2 To enlist the TYPES OF INFERTILITY: Lecture cum Enlist the types

min types of discussion of infertility
infertility Primary Infertility PPT
Secondary Infertility

• Primary infertility: It applies to those who have

never conceived inspite of bring in a regular
 relationship with partner/spouse.

• Secondary infertility: It refers to the case where

conception has failed to occur after a period of
fertility.

• STERILITY: it’s an absolute state of inability to

conceive

6 3 To Explain the FACTORS RESPONSIBLE FOR INFERTILITY: Lecture cum Explain the
min factors discussion factors
responsible for • Healthy spermatozoa should be deposited high in PPT responsible for
infertility vagina. infertility
• Motile sperm ascend through the cervix into uterine
cavity and fallopian tubes.
• There should be ovulation.
• The fallopian tubes should be patent and oocyte
should be picked up by fimbriated end of the tube.
• Sperm should be picked up by fimbriated end of the
tube.
• Sperm should fertilize oocyte at the ampulla of tube.
• Embryo should reach the uterine cavity after 3-4 days
of fertilization.
• Endometrium should be prepared for implantation.

7 15 To Explain CAUSES OF INFERTILITY: Lecture cum Explain

min Causes of discussion Causes of
infertility • Depends on both partners fertility potential, male PPT Infertility
account for 30-40%,female account for 40-50% of the
cases and 10% cases in which both partners are
responsible.
 • Causes in female
• Causes in male
• Combined factors
CAUSES IN FEMALE:
1. Dyspareunia and vaginal causes
2. Congenital defects in the genital tract
3. Infection in the lower genital tract Lecture cum
4. Cervical factors discussion
5. Uterine factors PPT
6. Tubal factors
7. Ovaries
* Anovulation
* Luteal phase defect
8. Peritoneal causes
9. Chronic ill health

1. Dyspareunia: important organic causes are-

• Rigid or imperforate hymen
• Congenital stenosis
• Acquired stenosis
• Traumatic stenosis
• Prolapsed ovaries associated with retroversion
2. Congenital defects in the genital tract:
• Absent or septate vagina
• Hypoplasia or absent uterus
3. Infection in the vagina and cervix : Although mild
infection may not prevent sperms fast getting into the
cervical canal, it is prudent to clear the infection
before any therapeutic measures are applied.
4. Cervical factors (5%) :
• Elongation of cervix
• Uterine prolapse
• Polyp in cervical canal
 5. Uterine causes( 10%) :
 Uterine hypoplasia
 Inadequate secretory endometrium
 Fibroid uterus
 Endometritis
 Congenital malformation of uterus

6. Tubal factors(25-30 %) :
 Defective ovum picked up.
 Impaired tubal motility.
 Loss of cilia.
 Partial or complete obstruction of tubal lumen.
Fimbrial end blockage

7. Ovaries :
a) Anovulation or oligoovulation:

 No ovulation, no corpus luteum, no secretory

endometrium, absence of progestrone.

b) Inadequate growth and functioning of corpus

luteum.

 Inadequate progestron secretion.

 Life span of corpus luteum is < 10 days or there is
insufficient progestron secretion of progestron.
 As a result, there are less secretory changes in the
endometrium which hinder implantation.

8. Peritoneal causes :

 Peritubal adhesions by kinking the fallopian tubes

 cause blockage of the tubes.
 These adhesions form part and parcel of pelvic
inflammatory disease.
 Impair the peristaltic movements of the fallopian
tubes.
 In pelvic endometriosis, macrophages in the peritoneal
fluid may engulf the ovum and sperms preventing
fertilization.

9. Chronic ill health :

 Hypothalamic disease
 Pituitary disease
 Hypothyroidism
 Adrenal cortical insufficiency.

8 8 To describe the PATHOPHYSIOLOGY IN FEMALES: Lecture cum Describe the

min Pathophysiolog  Hypothalamus dysfunction discussion Pathophysiology
y PPT In females
In females Ant. Pituitary
1

Dec.gonadotropins inc. prolactin

Ovaries

Abnormal levels of FSH, LH,

estrogen, progesterone
  Anatomical defects

Obstruction in movement of ova

No fertilization

Infertility

Anovulation & menstrual problems

CAUSES IN MALE:
1. Defective spermatogenesis
2. Obstruction in efferent duct
3. Failure to deposit sperm high in vagina
4. Defect in sperm and sperm morphology

1. Defective spermatogenesis :
• Undescended testis
• Genetic
• Testicular toxins
- drugs
- radiation
• Endocrinal
- thyroid dysfunction
- GnRh deficiency
• Primary testicular failure
- varicocele
- cryptotorchism
- immunological
- orchitis
2. Obstruction in efferent duct:
a) Congenital
* absence of vas deferens
b) Acquired
 * Infection ( tuberculosis, gonorrhea)
* surgical trauma (vasectomy)

3.Failure to deposit sperm high in vagina

• Impotency
• Hypospadias
• Ejaculatory failure
• Drug related

4. Defect in sperm and seminal fluid:

• Immotile sperm
• Sperm antibodies
• Undue viscosity

9 7 To explain Lecture cum Explain

min pathophysiology PATHOPHYSIOLOGY IN MALES discussion pathophysiology
in males and PPT in males and
combined Inc. scrotal temp combined
factors of factors of
infertility infertility
Germ cells damage

Infertility

• Bacterial & viral infections

Bioactive cytokines

Inflammation
 Inc. scrotal temp

Germ cell damage

infertility
COMBINED FACTORS:
• Advanced age of wife beyond 35 years.
• Infrequent coitus due to lack of knowledge of coitus,
technique and timing of coitus ( to utilize fertile
period).
• Anxiety and apprehension.
• Use of lubricants which may be spermicidal.
• Obesity - coitus difficulty
smoking – defective spermatogenesis due to nicotine
alcohol - paired sexual function
diabetes- impotency

• Excessive use of drugs like

 antiepileptic
 antipsychotic
 antihypertensive
 cimetidine
 chemotherapy
 nitrofurantoin
 beta-blockers
 spirolactone
 estrogen
 excessive use of testosterone and anabolic steroid
by athletes.
 SECONDARY INFERTILITY:

FEMALES :
• Uterine synaechiae
• Endometrial tuberculosis
• Pelvic endometriosis
• Vaginal stenosis
• Cervical stenosis
• Post MTP cornual block
tubectomy

MALES :
• Vasectomy
( obstructive azoospermia

10 15 To describe the Assessment: Lecture cum Describe the

min diagnostic test • History of discussion diagnostic test
for infertility for infertility
 age
 occupation
 educational background
 Duration of infertility
 past obstetrical
 menstrual cycle
 coital history
 Medical and surgical
 sexually transmitted diseases
* Frequent episodes of fever of any cause can suppress
spermatogenesis for as long as 6 months.

PHYSICAL EXAMINATION:
• In males it could be postponed until after the semen
analysis.
 • However , general height, weight, obesity, secondary
sex characters, thyroid enlargement should be looked
for.
• In females, height & weight of the woman, blood
pressure should be checked.
• Abnormal uterus and tubes (exposure to DES) via
bimanual examination should be looked for.

Tests for tubal patency:

• A mere patency of the tubal lumen is not the only

criteria to effect fertility. The normal physiological
functions of the fallopian tube is essential for
pregnancy to occur. The endosalpinx is lined by
ciliated epithelial cells & the secretory cells. The cilia
help in propulsion of the fertilized egg towards the
uterine cavity. The secretory cells provide nutrition to
the sperms as well as the ovum during the passage
across the tube.The peristaltic movements of the
fallopian tube are under the influence of oestrogen,
progesterone and prostaglandins and synchronized
movements help in the propulsion of sperms and
fertilized egg in the either direction. The ovarian
fimbriae are spread over the ovary at ovulation and
bring the ovum into the fimbrial end.

Hysterosalpingography:

• It’s the visualization of the uterine cavity and the

 fallopian tubes carried out by screening with the use of
an image intensifier in an x-ray room using a foley
catheter with 15 ml of the radiopaque dye injected into
the uterine cavity.
• complications: 1) pelvic infection
2) pain & collapse
3) allergic reaction

Laparoscopic chromotubation:

• It’s the laparoscopic visualization of the pelvis,

fallopian tubes and ovaries and injection of methylene
blue through the cervix.
• Used when hysterosalpinography has shown blocked
tubes.
• Its an invasive procedure & needs hospitalization.

Sonosalpingography:

• Also called as the “Sion test”

• In this test, under ultrasound scanning , a slow and
deliberate inj. of about 200 ml of saline into the
uterine cavity is accomplished via Foley catheter, the
inflated bulb of which lies above the internal os and
prevents leakage.
Its possible to visualize the flow of saline along the tube , and
 observe it issuing out as shower at the fimbrial end.

Newer modalities:

1. Hysteroscopy : The interstitial end of the fallopian

tube can be visualized. Cornual polyp is detected in 10
% cases and their biopsy can be taken.
2. Transcervical falloscopy : It visualizes the lumen of
the tubes. Hysteroscopic tubal cannulation at the
medial end can be therapeutic if the blockage is due to
mucus plug or mild flimsy adhesions.
3. Ampullary and fimbrial salpingoscopy : It is used to
study the mucosa of the fallopian tube in deciding
between tubal microsurgery and in-vitro fertilization.
Descending test using starch is injected into the pouch
of Douglas. The presence of starch in cervical mucus
24 hours later indicates patency of one or both tubes.

11 10 To enumerate Management of Tubal infertility: Lecture cum Enumerate

min management of discussion management of
infertility PPT, infertility
1. Tubal microsurgery : It is advocated in tubal
pamphlets
blockage. It has various names depending upon the
site of blockage. The risks of tuboplasty are:
* anaesthetic complications
* postoperative wound & chest infection
* embolism
* failure
* ectopic pregnancy
2. Laparoscopic tubal adhesiolysis, fimbrioplasty &
tubal surgery have yielded good results.
3. In-vitro fertilization: It is offered to women in whom
tuboplasty has failed or to women with extensive &
irreparable tubal damage. Contraindications to it are
 extensive pelvic adhesions & inaccessible ovaries due
to adhesions, ova retrieval in such cases may be
impossible
4. Tubal reanastomosis typically is used to reverse a
tubal ligation or to repair a portion of the fallopian
tube damaged by disease. The blocked or diseased
portion of the tube is removed, and the two healthy
ends of the tube are then joined. This procedure
usually is done through an abdominal incision
( laparotomy ).
5. Salpingectomy, or removal of part of a fallopian tube,
is done to improve in vitro fertilization (IVF) success
when a tube has developed a buildup of fluid
( hydrosalpinx ). Hydrosalpinx makes it half as likely
that an IVF procedure will succeed.
6. Salpingostomy is done when the end of the fallopian
tube is blocked by a buildup of fluid (hydrosalpinx).
This procedure creates a new opening in the part of the
tube closest to the ovary. However, it is common for
scar tissue to regrow after a salpingostomy, reblocking
the tube.
7. Fimbrioplasty may be done when the part of the tube
closest to the ovary is partially blocked or has scar
tissue, preventing normal egg pickup. This procedure
rebuilds the fringed ends of the fallopian tube.

Care After Surgery:

• After open abdominal surgery, there usually is a 2- to

3-day hospital stay. Antibiotics may be given to
prevent infection. A woman usually can return to work
in 4 to 6 weeks, depending on the extent of surgery,
the nature of her work, and her overall health and
stamina.
 • After laparoscopic surgery, there is a brief hospital
stay. A woman's return to daily activities can take a
few days to a couple of weeks, depending on the type
of procedure.

8. Ballon tuboplasty & cannulation is done through

transcervical route for medial end block.
9. Tubal cannulation
10. Gamete intrafallopian transfer (GIFT): In this, the
ovum with the sperms are placed in the distal end of
the fallopian tubes at ovulation under guidance of the
laproscope

11 5 To explain tests Tests of ovulation: Lecture cum Explain tests of

min of ovulation and Basal body temperature: It is established that BBT falls at discussion ovulation and
its management PPT its management
the time of ovulation by about ½ degree Fahrenheit.
Subsequently during the progestational half of the cycle the
temperature is slightly raised above the preovulatory level.
This is due to the thermogenic action of progesterone & is
hence presumptive evidence of the presence of a functioning
corpus luteum & hence ovulation.
2. Endometrial biopsy : It consists of curetting small
pieces of the endometrium from the uterus with a
small endometrial biopsy curette, preferably 1-2 days
prior the onset of menstruation.
• The material should be fixed immediately in formaline
saline & histologically examined..
• It is subjected to guinea pig inoculation & culture to
rule out genital tuberculosis.
3. Fern test : A specimen of cervical mucus obtained by
platinum loop is spread on a glass slide & allowed to
dry.
• Microscopic examination shows a characteristic
 pattern of fern formation ( estrogenic phase).
• This ferning disappears after ovulation. This ferning is
due to the presence of sodium chloride in the mucus
secreted under estrogen effect.
• At the time of ovulation, the cervical mucus is thin &
profuse that the patient may notice a clear discharge ,
the so called normal ovulation cascade.
• Spinnbarkeit or thread test : The ovulation mucus
has the property of great elasticity & can withstand
stretching upto 10 cm (estrogen activity)
• Tack : during the secretory phase, the cervical mucus
becomes tenacious & its viscosity increases so that it
loses the property of spinnbarkeit & fractures when
put under tension.This property is called tack.

TREATMENT DRUGS:
• Plasma progesterone : a low conc. of it needs,
♦ Administration of hCG 5000-10,000 IU weekly
♦ Micronized progesterone (oral) 100mg b.i.d or 300 mg
vaginal pessary twice daily.
♦ Weekly Prolution inj. 500mg
• Hyperprolactinaemia( > 25 ng/ml) : responds well to
1.25 mg bromocriptine at bedtime O.d for 7 days.

Drugs to manage Anovulation:

☻ Clomiphine citrate {CC} : ovulation should be

induced with it, with a dose of 50 mg/day to 100
mg/day starting from day 2 to day 6 of the cycle.
☻ Combination of cc & hMG: in polycystic ovarian
disease, ovulation is ideally induced with a
combination of cc & hMG ( human menopausal
 gonadotropin ) .
☻ Use clomiphine citrate 50-100mg/day from day 2 to
day 6 of the cycle. Inj. hMG 75 units I/M on day 3, 5
& 7 & more if so required.
☻ Prednisolone : 5mg at night & 2.5 mg every morning
till spontaneous ovulation sets in.

Semen analysis:
• The basic test to evaluate a man’s fertility is a semen
analysis. To perform this test, a man collects a sample
of his semen in a collection jar during masturbation
either at home or at the physician’s office.
• A man should abstain from ejaculation for several
days before the test, because each ejaculation can
reduce the number of sperm by as much as a third.
(The maximum number of sperm is usually obtained
by abstaining for about four days.)
• Proper collection procedure is important, since the
highest concentration of sperm is contained in the
initial portion of the ejaculate. The sample should be
kept at body temperature and delivered promptly,
because if the sperm are not analyzed within two hours
or kept reasonably warm, a large proportion may die
or lose motility.
• A semen analysis should be repeated at least three
times over several months..
• The analysis should report any abnormalities in sperm
count, motility, and morphology as well as any
problem in the semen.
• Total volume: 3-5 ml ( average 3.5 ml), viscous
• Sperm count: 60-120 million/ml (average 100
million )
• Motility: 80-90 % (average 80%)
 • Morphology: 80% or more normal ( average 80% )
• pH: 8
Ώ Pus cells should be absent.
Ώ Seminal fluid normally contains fructose.
Ώ Aspermia – means no sperm
Ώ Azoospermia- implies no sperm is seen.
Ώ Asthenospermia – no motile sperm or dimnished
motility.
Ώ Necrospermia- dead sperms
Ώ Teratospermia- abnormal morphology of sperms
Ώ Counts below 20 million/ml are usually associated
with infertility.

Postcoital test:
• The postcoital, also known as Simms–Huhner test is
designed to evaluate the effect of a woman’s cervical
mucus on a man’s sperm.
• To perform this test, a woman is asked to come into
the physician’s office within two to 24 hours after
intercourse at mid–cycle (when ovulation should
occur).
• A small sample of cervical mucus is obtained and
examined under a microscope. A problem is detected
if the physician observes no surviving sperm or no
sperm at all.

• If results are poor, the woman’s cervical mucus should

also be cultured for the presence of infection.
• The test can indicate that a problem exists but cannot
determine its cause in most cases. The test also cannot
evaluate sperm movement from the cervix into the
fallopian tubes or the sperm’s ability to fertilize an
 egg. Penetration less than 3 cm at 30 min. is abnormal.

Antisperm Antibodies Test:

• If a man has had a vasectomy reversed and still cannot

conceive or if semen analysis shows sperm clumping
together, blood tests for anti–sperm antibodies will be
conducted. The primary negative effect of these
antibodies is to bind the sperm to the woman’s
cervical mucus, preventing the sperm from swimming
further. up.
• The best method available today is one such uses
immunobeads, which allow determination of the
location of the antibodies on the sperm surface. If they
are present on the sperm head they can interfere with
the sperm’s ability to penetrate the egg; if they are
present on the tail they can retard sperm motility

Sperm penetration test:

• Since the basic function of a sperm is to fertilize an

egg, scientists were very excited when they found that
normal sperm could penetrate a denuded (zona-free)
hamster egg.
• A zona-free hamster egg is obtained from hamsters
and the covering (the zone) removed by using special
chemicals. The egg are then incubated with the sperm
in an incubator in the laboratory.
• After 24 hours, the eggs are checked to ascertain how
many sperm have been able to penetrate the egg. The
result gives a penetration score, which gives an index
of the sperm’s fertilizing potential. This is a very
delicate technique and is not available in India.
Semen-cervical mucus contact test:

• Equal quantity of semen & mucus is mixed, so there is

no interface. In presence of antibodies more than 25%
sperms show jerky or shaky movements by 30 min.
The cross check with the donor semen will indicate the
source of antibodies, whether it is cervical or seminal
antibodies

Testicular Biopsy:

• Occasionally, a testicle biopsy may be performed in

which tissue samples are removed under anesthesia.
• A biopsy is most useful for detecting obstruction in the
transport system when sperm production looks normal
but the count is low.
• The standard biopsy procedure requires incisions
(called an open approach) and can be painful
afterward.
• The procedure is valuable not only for diagnosis of
infertility and predicting fertility treatment success,
can be used to retrieve sperm for fertility procedures
too.

Chromosomal study:

• Karyotyping should be undertaken in cases of

azoospermic men, as 15- 20% of them have
chromosomal disorders. The most common is
KLINEFELTER’S SYNDROME with 47 XXY
karyotype.
 • Ultrasound : Ultrasound scanning of the scrotum
detects scrotal volume, hydrocele.
• Vasogram : It is required when normal FSH level is
associated with azoospermia
• Urinalysis : In suspected retrograde ejaculation, urine
is made alkaline before collection & centrifuged . The
presence of sperms in the urine proves retrograde
ejaculation.

12 10 To explain Management of male infertility: Lecture cum Explain

min management of discussion management of
Male infertility • Antibiotics like Doxycycline 100mg b.i.d for 6 weeks PPT Male infertility
to treat infection.
• Hormones like testosterone, pituitary hormones &
GnRH to improve spermatogenesis.
Bromocriptine is useful in hyperprolactinaemia

• HCG : 10,000 IU I/M weekly for 10 weeks improves

testosterone secretion, & pregnancy rate by 38 %.
Alternatively 5000 IU may be given twice a week.
• Testosterone : 25-50 mg daily (orally) improves
testicular function. A larger dose of 100-150 mg daily
suppresses spermatogenesis.
• Clomiphine : 25 mg daily for 25 days followed by rest
for 5 days is given cyclically for 3-6 cycles in
hypogonadal infertility.
• hMG : 150 IU thrice a week for 6 months is
recommended in pituitary inadequacy.
• Tamoxifen : 10 mg daily for 6 months.
• Dexamethasone : 0.5 mg daily or 50 mg Prednisone
daily for 10 days each for 3-6 months to treat spermal
antibodies.
 • Sidenafil (viagra) : 25-100 mg one hr before coitus
improves erectile function. But recent reports on
cardiac ischemic heart disease is alarming, along with
color visual disturbances & headache have also been
reported. Its contraindicated in men on hypotensive
drugs.
• Artificial insemination : The donor for insemination is
screened for HIV, STD & hepatitis B & a good quality
of semen confirmed.
Management of Azoospermia:

• With oligospermia or abnormal semen, the couple may

be offered:
∞ In-vitro fertilization (IVF)
∞ Gamete Intrafallopian Transfer (GIFT)
∞ Micro-Assisted Fertilization technique (MAF)
∞ Microsurgical Epididymal Sperm Aspiration (MESA)
or Percutaneous Epididymal Sperm Aspiration
(PESA)

13 3 Summary:
min
• Definition of infertility
• Incidence of infertility
• Etiology of infertility (in males and females)
• Diagnostic tests for infertility (males and females)
• Management of infertility (males and females)

14 2 Recapualization:
min
• Define infertility
• What are the incidence rate of infertility
 • Explain etiology of infertility
• Describe diagnostic tests for infertility
• Explain Management of infertility
Bibliography:
 Brunner & suddarth. text book of medical surgical
nursing (10th): 1400-03.

 Black Joyce M,Hawks Jane Hokanson .Medical

Surgical Nursing 2009; 1(8th):866-904.

 Phipps , sands & Marek. Text book of medical

surgical nursing;(6th):1529-70.
SELF IDENTITIFICATION DATA

Subject: Obstetrics and Gynecological Nursing

Topic: Infertility

Name: Anita

Date of presentation 24.6.2014

Type of teaching lecture cum discussion

Group B.SC 4th year

Time 1 hour

Place Classroom

Av aids Power point presentation, Pamphlets

General objective: At the end of teaching the group will be able to understand about Infertility

Specific Objectives: At the end of discussion the students will be able to –

• Define infertility
• Enumerate the incidence rate of infertility
• Explain etiology of infertility
• Describe diagnostic tests for infertility
• Explain Management of infertility
 practice teaching -1
TOPIC infertility

SUBMITTED TO SUBMITTED BY
RESPECTED PRABHJOT KAUR
MRS,DALJIT PRAKASH M.SC.NSG 1ST YR.
MAM,PROFESSOR
M.SC. NURSING,OBG.
submitted on
24-6-14