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the Earn 1 FREE Omnia Contact Hour cmetm journal

special edition | March 2013

special edition: Fertility Nursing

Infertility: Causes and Considerations

Causes of : A Nursing Perspective Jamie S. Leonard, RN

Addressing Weight in Fertility Settings Monica Moore, MSN, RNC

Ethics, Psychological Concerns and Practical Interventions for Fertility Clinics Kelly L. Lehl, RNC, BSN

www.OmniaEducation.com author Causes of Infertility: Jamie S. Leonard, rn RN – IVF A Nursing Perspective Texas Fertility Center austin, tx

nfertility is a disease defined by the Patients typically present with irregular peer reviewer failure to achieve a after 12 or absent menses. Ovulatory dysfunction Monica Moore, msn, rnc months (in women under 35 years of can stem from functional and hormonal Nurse Practitioner I RMA of Connecticut Iage) or 6 months (in women over 35 years causes. Premature ovarian failure (POF) of age) when having regular unprotected describes when there is loss of ovarian norwalk, ct intercourse.1 Infertility is a multidimensional function before the age of 35, and the issue that can be caused by a variety of malady is most often genetically inherited. medical editor conditions, including polycystic ovarian POF can also be caused by the ovary Dick Barnett syndrome (PCOS), , uterine being damaged or destroyed by disease Medical Editor influences, tubal disease, male factor, and processes such as endometriosis or ovarian teaneck, nj recurrent spontaneous . The nurse tumors. Hormonal factors can include plays a vital role in educating their patients , hypothalamic dysfunction, year, or periods that are prolonged and may about the cause(s) of their infertility, or hyperprolactinemia, hyperandrogenism, and either be light or heavy flow. For patients diagnosis, as well as making sure they PCOS. with PCOS who are trying to conceive, understand all aspects of the treatment PCOS is considered the most common clomiphene citrate remains the treatment process. Infertility nurses also provide endocrinologic disorder in women of of choice for ovulation induction. Patients support for their patients throughout their reproductive age, affecting between 6% should be advised to alert their nurse of infertility journey. and 10% of patients.4 The clinical expression any adverse effects while they are taking of PCOS can vary greatly from person this medication. If there is no ovulatory Ovarian Factors to person, but typically includes obesity, response to clomiphene, the physician Circumstances relating to the ovary account hyperandrogenism, enlarged ovaries, or may recommend moving on to controlled for 25% of cases,2 and infrequent, irregular, or absent ovulation. ovarian hyperstimulation (COH) with these include oligo-ovulation or intrauterine insemination (IUI) or in vitro and diminished ovarian reserve. The Approximately 60% to 70% of women with fertilization (IVF). term ‘ovarian reserve’ indicates a woman’s PCOS are overweight or obese, a situation reproductive capability by evaluating the that has been linked to failure or delayed If COH/IUI or IVF is recommended, it quantity and quality of her remaining response to treatments. As a result, weight is imperative to discuss all aspects of the oocytes. It is generally accepted that the loss should be recommended as a first-line cycle before beginning this treatment, such numbers of oocytes peak as a fetus, begin therapy in overweight women with PCOS as frequent monitoring to ascertain that to lessen thereafter, and do not regenerate.3 who are trying to conceive. Patients should the patient is responding appropriately to Diminished ovarian reserve occurs when the be encouraged to set realistic weight-loss the stimulation protocol. The signs and ovary has a reduced number of oocytes than goals as losing as little as 5% of the initial symptoms of ovarian hyperstimulation would be expected in woman of comparable body weight can help improve the rate syndrome (OHSS) should be discussed age. Although it is well-know that female of spontaneous ovulation.4 The nurse’s as well to ensure patient safety during the fertility declines with age, determining role might include referring the patient to cycle. Individuals must also be made aware the rate of decline is difficult. Evaluating a a weight-management clinic, behavioral of the possibility of multiple woman’s ovarian reserve is of the utmost counselor, or nutritionist. as well as cancellation of the cycle due to importance as it can help to predict OHSS. IVF may be a better treatment reproductive potential. Diminished ovarian Menstrual irregularities are the most option than COH/IUI for those with PCOS reserve does not preclude the chances of common characteristic associated with as the risk for multiple pregnancies and conceiving, but treatment should not be PCOS. It is important for nurses to gather OHSS can be reduced. Freezing embryos delayed as time is of the essence. information about their patients’ cycles instead of transferring them is also an option and treatment goals. Those with PCOS to prevent severe OHSS. Oligo-ovulation and anovulation are very most commonly have cycles longer than common disorders associated with infertility. 35 days, fewer than 8 menstrual cycles per

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Endometriosis Uterine Factors determine the best treatment Endometriosis is a common condition Factors involving the can play a recommendation for the patient. The that occurs when the normal tissue from major role in a woman’s fertility. Some location of the fibroid and its relationship the attaches to organs in uterine defects occur from birth and are to the uterine cavity are key in determining the and begins to grow. It has been referred to as mullerian abnormalities, whether the structure will negatively affect theorized that retrograde menstruation of which may develop when the uterus does fertility.8 Submucosal fibroids, or those that viable endometrial cells passes through the not develop normally and, most commonly, grow into the inner uterine cavity, should be fallopian tubes and adheres to the pelvic include septate, bicornuate, or unicornuate removed prior to fertility treatments as they organs, thereby allowing the endometrial uterus, as well as uterine didelphys. A can decrease pregnancy rates as much as cells to grow outside the uterus. The can be repaired surgically, 70%.9 Submucosal fibroids are typically relocation of the endometrial tissue can with evidence showing an increase in the removed hysteroscopically. On the other cause irritation to the pelvis and contribute pregnancy outcome. However, the other hand, serosal and some intramural fibroids to pain and infertility.5 Early studies have abnormalities are not repaired because can be removed laparoscopically, but some suggested that 25% to 50% of infertile the pregnancy outcomes do not improve of these tumors are too large and will require women have endometriosis and that 30% after surgery.7 laparotomy. to 50% of those with endometriosis are Other uterine factors that may Nurses should prepare their patients for infertile, with infertile women usually being 6 affect fertility are polyps, adhesions both the procedures and potential surgery to 8 times more likely to have endometriosis (Asherman’s syndrome), and fibroids. by reviewing instructions and discussing the than fertile women. The patient history Asherman’s syndrome is characterized plan for pain management as these can be should focus on symptoms such as by the development of scar tissue in the somewhat uncomfortable postoperatively. , , cyclic pain or endometrial layer of the uterus and the The recovery time and healing period chronic . . This usually occurs after repeated vary greatly between laparoscopy and Although the above symptoms are surgical procedures, but it can also occur laparotomy, so the nurse will also follow up suggestive of endometriosis, laparoscopy from severe pelvic infections. Asherman’s with the patient after surgery to ensure the is required for a definitive diagnosis,6 syndrome can be managed with surgical woman is recovering as expected and to set and patients are very often anxious intervention. up a postoperative visit with the physician. about undergoing a surgical procedure. Uterine fibroids are benign tumors that Tubal Disease/Ectopic Pregnancy If the patient and physician agree on are composed of muscle tissue that can Tubal disease is one of many causes of laparoscopy, it is imperative that the nurse change the shape or size of the uterus. female infertility and serves as the primary thoroughly explain the surgical procedure These structures are quite common and are diagnosis in 25% to 35% of all female and postoperative considerations so the found in 5% to 10% of those with infertility. infertility cases.10 Any history of ectopic patient knows what to expect. Many Fibroids that are known to decrease the pregnancy, chlamydia, gonorrhea, pelvic people perceive surgery as a delay in their potential for fertility are usually situated inflammatory disease, endometriosis, or treatment. Sometimes it is helpful to explain within the uterine cavity, in addition to larger pelvic surgery may alert the clinician to to the woman that laparoscopy is not only ones found in the uterine wall. They can also suspect that tubal factor may play a role diagnostic, but the procedure also allows result in infertility by changing the position in infertility. Hysterosalpinogram (HSG) is the physician to treat their endometriosis, of the cervix, which can interfere with sperm the standard first-line evaluation of tubal potentially increasing her chances for traveling through the cervix. Depending patency.8 conception, since laparoscopic ablation has on their location, fibroids can also alter the been associated with a significant increase in The patient may experience cramping or shape of the uterus and impede the normal live birth rates.6 discomfort after the HSG which should blood flow to the endometrium, thereby resolve shortly after the examination is The severity of endometriosis, or staging, impairing or preventing implantation. In completed. Some factors that need to may dictate the recommended treatment addition, fibroids may block the fallopian be considered to determine if corrective after surgery. For women with mild tubes and diminish sperm and/or embryo surgery or IVF is the appropriate path to endometriosis, COH with IUI may be transport. take include the patient’s age and ovarian a reasonable option. Patients who have The location and size of fibroids are reserve, the site and extent of the tubal moderate to severe disease, in which the evaluated by hysterosalpingogram, saline disease, and presence of any other infertility endometriosis distorts the pelvic anatomy, sonogram, hysteroscopy, and/or MRI. issue. Semen analysis should be performed may opt for IVF since it maximizes their These imaging studies allow physicians to in the early stages of the fertility evaluation. chances for pregnancy. If male infertility is also discovered, IVF losses, a thorough evaluation is necessary. may be the best option for treatment. It is important for the Approximately 25% of pregnancies result in There are advantages and disadvantages nurse to ensure that the , with fewer than 5% of women to tubal surgery and IVF, which need to be patient is well-informed experiencing two consecutive discussed with the patient. The advantage and only 1% having three or more.14 to tubal surgery is that it is a minimally of the probable cause(s) The basic diagnostic testing for recurrent invasive outpatient procedure that can of her infertility, the pregnancy loss includes: obtaining karotypes afford patients the opportunity to try to treatments options of each parent (this is accomplished conceive each month without any further available, and the risks and by chromosomal analysis using a blood intervention for this and subsequent benefits of those therapies. test), cervical cultures, an evaluation of pregnancies. IVF is often recommended the uterine cavity, and antiphospholipid for patients with tubal disease, as the antibodies testing. The treatment can advantage to proceeding with IVF is that the rate of pregnancy and implantation. vary for each patient and is dependent there is a much greater per-cycle success Hydrosalpingeal fluid is strongly suspected on what is found during the diagnostic rate. The surgery is less invasive than the of being embryotoxic and, in turn, affect testing. If an anatomic defect is found, it is tubal type, significantly reducing the risk of embryo development, but the exact cause most often treated by surgical correction. an ectopic pregnancy. is still unknown. In addition, salpingectomy If the parental are abnormal, In some cases, IVF is the only option for has been effective in improving the success the use of an egg or sperm donor may patients with tubal disease. This is especially rates of IVF by removing the source of the be necessary. Infections are typically 12 true when patients have extensive adhesions, hydrosalpingeal fluid. treated with a course of antibiotics, while endometriosis, ectopic pregnancy, or Ectopic pregnancies are conceptions that therapy for hematological factors usually fallopian tubes that are damaged beyond implant outside of the uterine cavity. Any involves low-dose aspirin and heparin. The repair because of infection. IVF is also the woman can have an ectopic pregnancy, physician, however, may recommend further way to proceed when surgical sterilization is but previous history of damage to the evaluation by a hematologist. In the instance done and the physician is unable to perform fallopian tubes places a patient at higher of hormonal disorders, , tubal reanastomosis. Patients are often risk. Other factors that would increase replacement, or dopamine agonists reluctant to have damaged tubes removed the potential for ectopic pregnancy are are utilized. because IVF is then the only alternative previous histories of ectopic pregnancy, Many early miscarriages are caused by to achieve conception. Nurses must teach tubal surgery, sexually transmitted disease, a random chromosomal abnormality in patients that leaving damaged, blocked pelvic inflammatory disease, IUD use, and/ the embryo that is known as , tubes in place can actually decrease their 13 or cigarette smoking. Close monitoring of and it is postulated that more than 60% chances for pregnancy. Tubal surgeries in high-risk patients is advised, as the prompt of early pregnancy losses are traceable to which the tubes are unblocked by surgical diagnosis of an ectopic pregnancy may chromosomal abnormalities.14 cannulation may increase the potential for improve the success of medical intervention. an ectopic pregnancy. Even though an ectopic pregnancy is not There are also many times when the cause of miscarriage is unknown, which When the becomes viable, the nurse must provide support to can be difficult for patients to understand. obstructed, it can collect fluid and become the patient as she mourns the loss of her Unfortunately there is no explanation in a . This is most commonly pregnancy. Feelings of sadness, anger, and 50% to 75% of couples with recurrent caused by an old infection, such as a even guilt are all normal in the processes of pregnancy loss.14 sexually transmitted disease, or may be healing and grieving. the result of previous surgeries and severe Recurrent Pregnancy Loss When nurses counsel patients who have pelvic adhesions.11 The presence of a The definition of recurrent pregnancy experienced this type of pregnancy loss, hydrosalpinx needs to be addressed before loss is two or more consecutive failed empathizing with these women and allowing initiating fertility treatments. Even if the pregnancies. When recurrent loss occurs, them to appropriately mourn is of utmost patient is planning to proceed with IVF, it is there can be a multitude of reasons. The importance. It should be emphasized that essential to surgically correct or remove the causes of miscarriage can be related to there is a 50% to 70% chance of having a hydrosalpinx prior to beginning the cycle. maternal age, infections, and/or genetic, successful pregnancy after a loss. Promoting The presence of hydrosalpinx has had a chromosomal, uterine, immunologic or a healthy lifestyle, such as smoking cessation negative effect on IVF cycles as it decreases hormonal abnormalities. After three or more and decreasing alcohol and caffeine

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consumption should also be stressed. Fertil Steril. 2012;98(5):1407-1415. Achieving a healthy body weight is strongly notes from the Doc 4. Fauser BC, Tarlatzis BC, Rebar RW. Consensus on suggested as women with very high and women’s health aspects of polycystic ovary syndrome Eric S. Surrey, md, facog (PCOS): the Amsterdam ESHRE/ASRM-Sponsored very low body mass index (BMI) are more 3rd PCOS Consensus Workshop Group. Fertil Steril. likely to have miscarriages.15 2012;97(1):28-38. Jamie S. Leonard, RN provides a superb 5. Lessey BA. Medical management of endometriosis and Unknown or Idiopathic Infertility overview of several commonly confronted infertility. Fertil Steril. 2000;73(6):1089-1096. Infertility that is unknown or idiopathic diagnoses in . It is critical 6. The Practice Committee of the American Society for occurs when a couple completes their that specialists complete a Reproductive Medicine. Endometriosis and infertility. infertility testing and there is no definitive thorough evaluation of each of their patients, Fertil Steril. 2006;86(4):S156-S160. diagnosis. Unexplained infertility occurs in even if they present with an obvious cause of 7. Uterine Abnormalities: Uterine septums, scarring, and infertility such as a tubal occlusion. Ovarian structural causes of infertility. (n.d.) Retrieved 2013, from approximately 20% to 35% of couples, and Texas Fertility Center. www.txfertility.com/03uterine- reserve and sperm function testing, as well as can be very frustrating since everything abnormalities.php. a thorough evaluation of the uterine cavity appears normal, but conception has yet to 8. Fibroids and Fertility. (2011) Retrieved 2013, from occur. There are many treatment options and fallopian tubes should be performed. reproductivefacts.org. http://reproductivefacts.org/ It is also important that associated health available for unexplained infertility, such as Fibroids_and_Fertility. issues be addressed. Patients with polycystic COH/IUI or IVF, so nurses should highlight 9. Bouwsma EV, Gorney KR, Hesley GK, Jensen JR, ovarian syndrome in particular should also Peterson LG, Stewart EA. Magnetic resonance-guided the impressive success rates with therapy undergo evaluation of glucose intolerance and focused surgery for leiomyoma-associated that have played out time and again, even infertility. Fertil Steril. 2011;96(1):e9-e12. cardiovascular risks and lipid abnormalities. when the cause of infertility is unknown. A thorough assessment of the uterine cavity 10. The Practice Committee of the American Society for Reproductive Medicine. Committee opinion: role of tubal Male Infertility should be an integral part of any patient surgery in the era of assisted reproductive technology. Male factor is the primary cause of infertility who is preparing for assisted reproductive Fertil Steril. 2012;97(3):539-545. for 20% of couples and contributory in technologies. The evaluation and treatments 11. Hydrosalpinx. (2008) Retrieved 2013, from 16 should be targeted and evidence based. reproductivefacts.org. http://www.asrm.org/ another 30% to 40%. Male infertility may Hydrosalpinx_factsheet result from a variety of conditions, many 12. Nackley AC, Muasher SJ. The significance of which can be identified and treated. Semen hydrosalpinx in in vitro fertilization. Fertil Steril. analysis is essential to evaluate the male (ICSI) the best option for the couple. IVF 1998;69(3):373-384. partner, as the procedure identifies the is typically recommended with lower sperm 13. Van Mello NM, Mol F, Ankum WM, Mol BW, van presence and degree of the male factor so counts because the procedure significantly der Venn F, Hajenius PJ. Ectopic pregnancy: how the increases the exposure of oocytes to sperm diagnostic and therapeutic management has changed. that recommendations for treatment can Fertil Steril. 2012;98(5):1066-1073. and therefore can improve fertilization rates. be made. The components of the semen 14. Recurrent Pregnancy Loss. (2008) Retrieved 2013, analysis include sperm motility, morphology, In conclusion, there are many causes of from reproductivefacts.org. www.reproductivefacts.org/ concentration, and volume. It is quite Recurrent_Pregnancy_Loss infertility and it is important for the nurse to common for semen samples to vary from 15. Metwally M, Saravelos S, Ledger W, Phil D, Chiu Li T. ensure that the patient is well-informed of one collection to another, and the results Body mass index and risk of miscarriage in women with the probable cause(s) of her infertility, the recurrent miscarriage. Fertil Steril. 2010;94(1):290-295. can be optimized with at least two to five treatments options available, and the risks 16. The Practice Committee of the American Society days of abstinence. The patient should and benefits of those therapies. Infertility for Reproductive Medicine. Diagnostic evaluation of be provided with standardized collection the infertile male: a committee opinion. Fertil Steril. can be very stressful, so it is imperative instructions to improve quality control. If 2012;98(2):294-301. that the nurse provide the patient with semen analysis results are abnormal, refer 17. Van Voorhis BJ, Barnett MN, Sparks AE, Syrop competent, caring support both during and the patient to the urologist for a thorough CH, Rosenthal G, Dawson J. Effect of the total motile after her treatment. sperm count on the efficacy and cost-effectiveness of evaluation. intrauterine insemination and in vitro fertilization. Fertil Steril. 2000;75(4):661-668. In most cases, male factor infertility can references 1. The Practice Committee of the American Society for be treated with either IUI or IVF. IUI is Reproductive Medicine. Definitions of infertility and recommended for patients whose semen recurrent pregnancy loss. Fertil Steril. 2008;90(5):S60. analysis is normal and their total motile 2. Causes of female infertility. (2013) Retrieved February sperm count is 10 million or greater.17 If 2013, from UpToDate.com. http://www.uptodate.com/ the sperm count is lower than 10 million, contents/causes-of-female-infertility. the success rate of IUI declines, making 3. The Practice Committee of the American Society for Reproductive Medicine. Testing and interpreting IVF with intracytoplasmic sperm injection measures of ovarian reserve: a committee opinion.