NURSING CARE OF MALE AND FEMALE

CLIENTS WITH GENERAL AND SPECIFIC

PROBLEMS IN REPRODUCTION AND
SEXUALITY
Care of couple with problems of infertility:
1. Causes of infertility in males and females
2. Diagnostic tests
3. Nursing interventions
 CARE OF COUPLE WITH
PROBLEMS OF INFERTILITY
INFERTILITY
◦ It is the inability of a sexually active, non-contracepting couple to
achieve pregnancy in one year.
◦ a term used to describe the inability to conceive a child or sustain
a pregnancy to birth.
◦ Infertile (couple) if they have not become pregnant after at least 1
year of unprotected sex.
◦ Because most couples have the potential to conceive but they are
just less able to do this without additional help, the term
subfertility is more often used today.
One National Health Goal directly addresses the problem of subfertility:
• Reduce the proportion of married couples whose ability to conceive or maintain a
pregnancy is impaired from a baseline of 13% to a target of 10%
(http://www.nih.gov).

➢Nurses need to be active in health promotion and early identification and

prevention of problems that could lead to subfertility, playing active roles in
teaching clients about safer sex practices, to help reduce the incidence of sexually
transmitted infections and pelvic inflammatory disease, both of which can
contribute to subfertility.
Subfertility
◦ Subfertility is said to exist when a pregnancy has not occurred after at least 1
year of engaging in unprotected coitus (Hamilton, 2012)
➢A. Primary subfertility - there have been no previous conceptions;
➢B. Secondary subfertility - there has been a previous viable pregnancy but
the couple is unable to conceive at present.

◦ Sterility is the inability to conceive because of a known condition, such as the

absence of a uterus.
Statistics:
◦ Couples: 30% - it is the man who is subfertile
70%, it is the woman.
◦ Of women seen for a fertility evaluation:
➢20% to 25% experience ovulatory failure
➢20% experience tubal, vaginal, cervical, or uterine problems
➢10% of couples, no known cause for the subfertility can be discovered despite all
the diagnostic tests currently available. Such couples are categorized as having
unexplained subfertility
oAge is related to subfertility
oWomen who are using oral, injectable, or implanted hormones for contraception
may have difficulty becoming pregnant for several months after discontinuing these
medications,
FOR A COUPLE WITH SUBFERTILITY
◦Today, a subfertility investigation is usually limited to only three
assessments:
1. semen analysis
2. ovulation monitoring
3. tubal patency
 Fertility Assessment:
◦ Basic fertility assessment begins with a health history and physical examination of
both sexual partners.

A. Health History
History taking for women should include:
B. Physical Assessment
◦For the men
✓secondary sexual characteristics (pubic hair)
✓genital abnormalities:
➢absence of a vas deferens
➢presence of undescended testes
➢varicocele (enlargement of a testicular vein).
➢hydrocele (collection of fluid in the tunica vaginalis of the
scrotum) is rarely associated with subfertility but should be
documented if present.
For the women:
➢breast and thyroid examination is necessary to rule out
current illness.
➢Of particular importance are secondary sex
characteristics, which indicate maturity and good pituitary
function .
➢A complete pelvic examination including a Pap test is
needed to rule out anatomic disorders and infection.
C. Fertility Testing
Basic fertility testing is geared toward answering these questions:
1. Is there sperm of good quality and number available?
2. Are ova (eggs) available? – ex: woman is ovulating?
3. Is it possible for the sperm and egg to meet in a receptive environment?

Commonly used:
(1) semen analysis in the male
(2) ovulation monitoring and tubal patency assessment in the female.
Additional testing for men, if warranted:
✓Urinalysis ✓protein-bound iodine (a test
✓complete blood count for thyroid function)
✓blood typing, including Rh ✓cholesterol level (arterial
factor plaques could interfere with
✓serologic test for syphilis pelvic blood flow)
✓a test for the presence of HIV ✓ follicle-stimulating hormone
(FSH), luteinizing hormone
✓erythrocyte sedimentation rate (LH),
✓testosterone levels
Advanced testing for women may include:
✓a rubella titer ✓If a woman has a history of
✓serologic test for syphilis galactorrhea, a serum prolactin
✓an HIV evaluation level will be obtained, as
increased prolactin levels reduce
✓a thyroid uptake determination the secretion of pituitary
✓assays for FSH, estrogen, LH, hormones.
and serial progesterone levels. ✓A pelvic sonogram may be
performed to rule out ovarian,
tubal, or uterine structural
disorders.
Male Subfertility Factors:
✓Disturbance in spermatogenesis (production of sperm cells)
✓Inadequate production of FSH and LH in the pituitary which stimulates the
production of sperm
✓Obstruction in the seminiferous tubules, ducts, or vessels preventing movement
of spermatozoa
✓Qualitative or quantitative changes in the seminal fluid preventing sperm motility
(movement of sperm)
✓Development of autoimmunity that immobilizes sperm
✓Problems in ejaculation or deposition preventing spermatozoa from being placed
close enough to a woman’s cervix to allow ready penetration and fertilization.
✓Chronic or excessive exposure to X-rays or radioactive substances, general ill
health, poor diet, and stress, all of which may interfere with sperm production
A. LIMITED SPERM COUNT
Sperm count is the number of sperm in a single
ejaculation or in a milliliter of semen.
The minimum sperm count considered normal has:
✓ 33 to 46M sperm per ml of seminal fluid, or 50M per
ejaculation
✓ 50% of sperm that are motile
✓ 30% that are normal in shape and form
LIMITED SPERM COUNT cont’n:
Factors:
✓chronic infection from tuberculosis or recurrent sinusitis, has the potential to raise
scrotal heat
✓Actions that directly increase scrotal heat, such as working at a desk job or driving
a great deal every day
✓Frequent use of hot tubs or saunas
✓Excessive weight may alter testosterone production and sperm production
✓Congenital abnormalities: cryptorchidism (undescended testes), varicocele, or
varicosity (enlargement) of the internal spermatic vein –slow/disrupt production
Testing for Sperm Number and Availability
1. Analysis of Pituitary Hormones
2. Semen Analysis
◦ may need to be repeated after 2 or 3 months because spermatogenesis is an
ongoing process and 30 to 90 days is needed for new sperm to reach maturity.
◦ Semen analysis includes the following steps:
Testing for Sperm Number and Availability
3. Sperm Penetration Assay and Antisperm Antibody Testing
➢With the use of an assisted reproductive technique such as IVF, poorly mobile
sperm or those with poor penetration can be injected directly into a woman’s
ovum under laboratory conditions (intracytoplasmic sperm injection), bypassing
the need for sperm to be fully mobile.
Therapy for Increasing Sperm Count and
Motility
✓a man may be advised to abstain from coitus for 7 to 10 days at a
time to increase the count.
✓Ligation of a varicocele (if present)
✓changes in lifestyle
• avoiding recreational marijuana use
• wearing looser clothing
• avoiding long periods of sitting
• avoiding prolonged hot baths
B. OBSTRUCTION OR IMPAIRED SPERM
MOTILITY
➢Diseases that can result in this type of obstruction because adhesions
form and occlude sperm transport
• mumps orchitis (testicular inflammation and scarring due to the mumps virus)
• epididymitis (inflammation of the epididymis)
• infections such as gonorrhea or ascending urethral infection
➢Congenital stricture of a spermatic duct
➢Benign Prostatic Hypertrophy (BPH)
▪Pressure from the enlarged gland on the vas deferens interfere with sperm
transport.
B. OBSTRUCTION OR IMPAIRED SPERM
MOTILITY cont’n
➢Infection of the prostate, through which the sperm and seminal fluid
must pass, or infection of the seminal vesicles (spread from a urinary
tract infection) can change the composition of the seminal fluid enough
to reduce sperm motility.
➢Anomalies of the penis:
◦ hypospadias (urethral opening on the ventral surface of the penis)
◦ epispadias (urethral opening on the dorsal surface)
◦ Peyronie disease (a bent penis) can cause sperm to be deposited too far
from the sexual partner’s cervix to allow optimal cervical penetration.
➢Extreme obesity in a male may also interfere with effective penetration
and deposition
Testing for Sperm Transport Disorders
◦Sperm transport disorders are suspected when FSH and LH
hormones, which stimulate the production of sperm, are
adequate but the sperm count remains limited.
Therapy for Sperm Transport Disorders
➢Obstruction:
◦ surgery to relieve the obstruction is extensive, costly, and may
not have a positive outcome.
◦ better solution can be extracting sperm from a point above the
blockage and injecting it into the vagina or uterus of the
man’s partner by intrauterine insemination (IUI)
➢problem appears to be that sperm are immobilized by vaginal
secretions - washing of the sperm followed by IUI may be
preferred.
C. EJACULATION PROBLEMS
1. Erectile dysfunction or the inability to achieve an erection (formerly
called impotence)
✓may occur from psychological problems
✓diseases such as a cerebrovascular accident, diabetes, or Parkinson disease
✓use of certain antihypertensive agents
✓discontinuation of finasteride, a drug used for male pattern baldness
A. Primary - if the man has never been able to achieve erection and
ejaculation
B. Secondary - if the man was able to achieve ejaculation in the past but
now has difficulty.
2. Premature ejaculation (ejaculation before penetration) - is
another factor that may interfere with the proper deposition
of sperm.
• It is another problem often attributed to psychological causes
• Adolescents may experience it until they become more
experienced in sexual techniques.
Testing for Ejaculation Concerns
✓identified by a sexual history. It may be difficult for a man to discuss this
area of his life, especially if a nurse is female, so skillful patient
interviewing technique is required.

Therapy for Ejaculation Concerns

✓psychological or sexual counseling
✓use of a phosphodiesterase inhibitor, such as sildenafil (Viagra) or tadalafil
(Cialis)
✓Dapoxetine, a short-acting selective serotonin reuptake inhibitor, is a drug
that has been developed especially for the treatment of premature
ejaculation and shows good results when taken about 1 hour before planned
coitus
Female Subfertility Factors:
➢Limited production of FHS or LH, which interfere with ova growth
➢anovulation (faulty or inadequate production of ova)
➢ problems of ova transport through the fallopian tubes to the
uterus,
➢uterine factors such as tumors or poor endometrial development,
and cervical and vaginal factors that immobilize spermatozoa
➢ In addition, nutrition, body weight, and exercise may compound
these problem
A. ANOVULATION

➢absence of ovulation or release of ova from the ovary

➢It is a common cause of subfertility in women
FACTORS:
✓genetic abnormality such as Turner syndrome (hypogonadism), in
which there is limited ovarian tissue available to produce ova
✓hormonal imbalance caused by a condition such as hypothyroidism,
which interferes with hypothalamus-pituitary-ovarian interaction
✓Ovarian tumors or polycystic ovary syndrome due to feedback
stimulation on the pituitary.
✓Chronic or excessive exposure to X-rays or radioactive substances,
general ill health, poor diet, and stress may all contribute to poor
ovarian function
✓glucose or insulin levels are too high, they can disrupt the production
of FSH and LH, leading to ovulation failure.
✓Stress
✓Decreased body weight or a body fat (excessively lean or
anorexic) can reduce pituitary hormones such as FSH and
LH and halt ovulation (termed hypogonadotrophic
hypogonadism
✓Polycystic ovary syndrome (PCOS), (Frequent cause) a
condition in which the ovaries produce excess testosterone,
thus lowering FSH and LH levels, which then causes irregular
and unpredictable menstrual cycles
➢ Polycystic ovary syndrome is associated with metabolic syndrome,
which is diagnosed in patients with:
✓ Waist circumference of 35 in. or more in women
✓ Fasting blood glucose over 100 mg/dl
✓ Serum triglycerides over 150 mg/dl
✓ Blood pressure over 135/85 mmHg
✓ High-density lipoprotein cholesterol over 50 mg/dl
✓ Development of hirsutism (unwanted body hair)
PCOS (Polycystic ovary syndrome)

◦ is a common condition that affects how a woman's ovaries work.

The 3 main features of PCOS are:
➢irregular periods – which means your ovaries do not regularly release
eggs (ovulation)
➢excess androgen – high levels of "male" hormones in your body, which
may cause physical signs such as excess facial or body hair
➢polycystic ovaries – your ovaries become enlarged and contain many
fluid-filled sacs (follicles) that surround the eggs.
Testing for Anovulation
a. Serum progesterone level
b. Basal body temperature (BBT)
c.Ovulation Determination by Test Strip
d.Pelvic sonogram - PCOS
Therapy for Anovulation
1. Administration of GnRH
◦ clomiphene citrate (Clomid) or letrozole (Femara) – stim ovulation
2. Administration of combinations of FSH and LH in
conjunction with administration of human chorionic
gonadotropin (hCG)- to produce ovulation.
3. If increased prolactin levels are identified, bromocriptine
(Parlodel) is added to the medication regimen to reduce
prolactin levels and allow for the rise of pituitary
gonadotropins
B. TUBAL TRANSPORT PROBLEMS
Pelvic inflammatory disease (PID) - is infection of the pelvic
organs: the uterus, fallopian tubes, ovaries, and their
supporting structures.
➢initial source of the infection is usually a STD such as chlamydia or
gonorrhea
➢left unrecognized and untreated, it enters a chronic phase,
which causes the scarring that can lead to stricture of the
fallopian tubes and the resulting fertility problem.
➢higher incidence among women who have multiple sexual
partners
Testing for Tubal Patency
1. Sonohysterosalpingogram - a sonographic examination of the fallopian
tubes and uterus using an ultrasound contrast agent introduced into the
uterus through a narrow catheter inserted into the uterine cervix followed
by intravaginal scanning.
2. Hysterosalpingogram is similar to a sonohysterosalpingogram except a
radiopaque contrast medium is used and the fallopian tubes are revealed
by X-ray
3. Transvaginal hydrolaparoscopy is begun with the instillation of a
paracervical local anesthetic block followed by introduction of a
hysteroscope into an incision just behind the cervix through the cul-de-
sac of Douglas into the peritoneal cavity
 Therapy for Lack of Tubal Patency
1. Diathermy or steroid administration may be helpful to reduce adhesions.
2. Canalization of the fallopian tubes and plastic surgical repair (microsurgery)
3. If peritoneal adhesions or nodules of endometriosis are holding the tubes fixed
and away from the ovaries, these can be removed by laparoscopy or laser surgery
4. IVF is more commonly used today and more apt to result in a viable pregnancy.
C. UTERINE CONCERNS
✓Tumors such as fibromas (leiomyomas) may be a rare cause of
subfertility if they block the entrance of the fallopian tubes into
the uterus or limit the space available on the uterine wall for
effective implantation.
 Endometriosis
◦ refers to the implantation of uterine
endometrium, or nodules, that have spread from
the interior of the uterus to locations outside
the uterus
◦ common sites spread to the fallopian tubes, the
cul-de-sac of Douglas, the ovaries, the uterine
ligaments, and the outer surface of the uterus
and bowel
Testing for Uterine Concerns
1.Sonogram (Hysteroscopy)
2.Uterine Endometrial Biopsy
3.Laparoscopy
Therapy for Uterine Concerns
➢If the problem of subfertility appears to be a luteal phase
defect, this can be corrected by progesterone vaginal
suppositories begun on the third day of a woman’s temperature
rise and continued for the next 6 weeks (if pregnancy occurs) or
until a menstrual flow begins.
➢If a myoma (fibroid tumor) or intrauterine adhesions are found
to be interfering with fertility, a myomectomy, or surgical
removal of the tumor and adhesions, can be scheduled
D. VAGINAL AND CERVICAL CONCERNS
◦ At the time of ovulation, the cervical mucus is thin and watery and can be easily
penetrated by spermatozoa for a period of 12 to 72 hours. If coitus is not
synchronized with this time, the cervical mucus may be too thick to allow
spermatozoa to penetrate the cervix.
◦ Infection or inflammation of the cervix (erosion) can also cause cervical mucus to
thicken so much that spermatozoa cannot penetrate it easily or survive in it
◦ A stenotic cervical os or obstruction of the os by a polyp may further compromise
sperm penetration.
◦ A woman who has undergone dilatation and curettage (D&C) procedures several
times or cervical conization (cervical surgery) should be evaluated in light of the
possibility that scar tissue and tightening of the cervical os has occurred
◦ Infection of the vagina can cause the pH of vaginal secretions to become acidotic,
thus limiting or destroying the motility of spermatozoa
Testing and Therapy for Vaginal and Cervical
Concerns
◦ Conjugated estrogen (Premarin) - low-dose estrogen therapy to
increase mucus production during days 5 to 10th day of her cycle.
◦ Vaginal infections such as trichomoniasis and moniliasis tend to recur,
requiring close supervision and follow-up.
➢If the woman’s sexual partner is the source of infection, and is therefore
reinfecting her, the partner needs antibiotic therapy as well.
➢Caution women who are prescribed metronidazole (Flagyl) for a Trichomonas
infection; although no studies have shown fetal malformations after its use, it
may be teratogenic early in pregnancy and therefore should not be continued if
the woman suspects she has become pregnant.
 E. Unexplained Subfertility
◦ It may be that the problem of one partner alone is not significant,
but when combined with a small problem in the other partner,
together, these become sufficient to create subfertility.
◦ It is obviously discouraging for couples to complete a fertility
evaluation and be told their inability to conceive cannot be
explained.
◦ Offer active support to help the couple find alternative solutions at
this point, such as continuing to try to conceive, using an assisted
reproductive technique, choosing to adopt, or agreeing to a child-
free life
Assisted Reproductive Techniques
1. ALTERNATIVE INSEMINATION - instillation of sperm from a
masturbatory sample into the female reproductive tract by means of a cannula
to aid conception at the time of ovulation
◦ IUI
◦ ICI
Assisted Reproductive Techniques
2. IN VITRO FERTILIZATION - most often used for couples:
✓who have not been able to conceive because the woman has obstructed or
damaged fallopian tubes
✓when the man has oligospermia or a very low sperm count.
✓when an absence of cervical mucus prevents sperm from entering the
cervix or antisperm antibodies cause immobilization of sperm.
✓couples with unexplained subfertility of long duration may be helped by
IVF.
Assisted Reproductive Techniques
3. GAMETE INTRAFALLOPIAN AND ZYGOTE INTRAFALLOPIAN TRANSFER
(GIFT) - ova are obtained from ovaries exactly as in IVF.
◦ Instead of waiting for fertilization to occur in the laboratory, however, both ova
and sperm are instilled, within a matter of hours, using a laparoscopic technique,
into the open end of a patent fallopian tube.
◦ Fertilization then occurs in the tube, and the zygote moves to the uterus for
implantation.
◦ It requires at least one patent fallopian tube
(ZIFT) - is similar to IVF in that the egg is fertilized in the laboratory, but
like GIFT,the fertilized egg is transferred by laparoscopic technique into the
end of a waiting fallopian tube. Although available, this technique is little used
today because of the extensive laparoscopic technique needed.
Assisted Reproductive Techniques
4. SURROGATE EMBRYO TRANSFER - technique for a woman who does
not produce ova.
◦ For the process, the oocyte is donated by a friend, relative, or an anonymous donor
◦ The menstrual cycles of the donor and recipient are synchronized by administration of
gonadotropic hormones.
◦ At the time of ovulation, the donor’s ovum is removed by a transvaginal, ultrasoundguided
procedure.
◦ The oocyte is then fertilized in the laboratory by the recipient woman’s partner’s sperm (or
donor sperm) and placed in the recipient woman’s uterus by embryonic transfer.
◦ Once pregnancy occurs, it progresses the same as an unassisted pregnancy.
PREIMPLANTATION GENETIC
DIAGNOSIS:
◦After the oocytes are fertilized in IVF and ZIFT procedures, the
DNA of both sperm and oocytes can be examined for specific
genetic abnormalities such as Down syndrome or hemophilia
◦Couples participating in intrauterine transfer and alternative
insemination can also have the sex of their children predetermined
using these methods.
 Alternatives to Childbirth
1. SURROGATE MOTHERS - a woman who agrees to carry
a pregnancy to term for a subfertile couple or an LGBT
couple
2. ADOPTION
3. CHILD-FREE LIVING