Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.

Chapter 7

Infertility, Contraception,

and Abortion

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Infertility

Incidence

Affects about 10% to 15% of reproductive-age

population

• Subfertility: prolonged time to conceive

• Sterility: inability to conceive

• Increases with age of woman, particularly in women 40

years and older

Diagnosis and treatment of infertility require

physical, emotional, and financial investment

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Infertility—cont’d

Factors associated with infertility

Female infertility

• Ovarian factors

• Tubal and peritoneal factors

• Uterine factors

• Vaginal-cervical factors

Isoimmunization

• Other factors

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Fig. 7-1. Abnormal uterus. A, Complete bicornuate uterus with vagina divided by a septum.

B, Complete bicornuate uterus with normal vagina. C, Partial bicornuate uterus with normal

vagina. D, Unicornuate uterus.

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Infertility—cont’d

Factors associated with infertility Male infertility

• Can be caused by structural and hormonal disorders

Undescended testes

Hypospadias

Varicocele (varicose vein of the scrotum)

Low testosterone levels

• Substance abuse

• Other factors

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Nursing Care Management

Assessment of female

Diagnostic tests

• Evaluation of the anatomy

• Detection of ovulation

• Hormone analysis

• Ultrasonography

• Endometrial biopsy

• Hysterosalpingography

• Laparoscopy

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Fig. 7-2. Hysterosalpingography. Note that the contrast medium flows through the intrauterine

cannula and out through the uterine tubes.

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Fig. 7-3. Laparoscopy.

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Nursing Care Management—cont’d

Assessment of male

Semen analysis

Hormone analysis

Scrotal ultrasound

Assessment of couple

Postcoital test

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Nursing Care Management—cont’d

Plan of care and implementation

Psychosocial

Nonmedical

• Herbal alternative methods

Medical

Surgical

• Assisted reproductive therapies

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Nursing Care Management—cont’d

Assisted reproductive therapies

In vitro fertilization-embryo transfer (IVF-ET)

Gamete intrafallopian transfer (GIFT)

Zygote intrafallopian transfer (ZIFT)

Ovum transfer (oocyte donation)

Therapeutic donor insemination (TDI)

Embryo adoption or hosting

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Fig. 7-4. 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.

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Nursing Care Management—cont’d

Reproductive alternatives

Adoption

Surrogate motherhood

Preimplantation genetic diagnosis

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Contraception

Intentional prevention of pregnancy

Birth control is the device or practice to

decrease the risk of conceiving

Family planning is the conscious decision on

when to conceive or avoid pregnancy

May still be at risk for pregnancy

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Nursing Care Management

A multidisciplinary approach to assist the

woman in choosing an appropriate

contraceptive method

Ideally the method should be safe, readily

available, economical, acceptable, and

simple to use

The safety of a method depends on a

woman’s medical history

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Contraception—cont’d

Methods

Coitus interruptus (withdrawal)

Fertility awareness methods (FAMs)

• Rely on avoidance of intercourse during fertile

periods

• FAMs combine charting menstrual cycle with

abstinence or other contraceptive methods

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Contraception—cont’d

Methods

FAMs

• Natural family planning (period abstinence)

• Calendar rhythm method

• Standard days method

• Basal body temperature method

• Cervical mucus ovulation-detection method

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Contraception—cont’d

Methods

FAMs

• Symptothermal method

• Predictor test for ovulation

• TwoDay method

• Lactation amenorrhea method

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Unn. Fig. 7-2. Cervical Mucus Characteristics

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Contraception—cont’d

Barrier methods Spermicides

Condoms, male (STI protection)

Vaginal sheath (STI protection)

Diaphragm • Fit of diaphragm

• Toxic shock syndrome

Cervical cap • Fit of cervical cap

Contraceptive sponge

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Fig. 7-11. Spermicides.

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Fig. 7-12. A, Mechanical barriers. Clockwise from top: female condom, cervical cap, diaphragm,

types of male condoms, vaginal ring (hormonal) (center). B, Contraceptive sponge.

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Unn. Fig. 7-4. Squatting

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Unn. Fig. 7-5. Leg-Up Method

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Unn. Fig. 7-6. Chair Method

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Unn. Fig. 7-7. Reclining

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Unn. Fig. 7-8. Preparation of Diaphragm

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Unn. Fig. 7-9. Insertion of Diaphragm

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Unn. Fig. 7-10. Diaphragm Insertion

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Unn. Fig. 7-11. Diaphragm Insertion

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Unn. Fig. 7-12. Diaphragm Insertion

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Unn. Fig. 7-13. Diaphragm Insertion

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Unn. Fig. 7-14. Cervical Cap Insertion

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Unn. Fig. 7-15. Cervical Cap Insertion

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Unn. Fig. 7-16. Cervical Cap Insertion

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Contraception—cont’d

Hormonal methods

Combined estrogen-progestin contraceptives

(COCs)

• Oral contraceptives and side effects

• Transdermal contraceptive system

• Vaginal ring

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Contraception—cont’d

Hormonal methods

Progestin-only contraceptives

• Oral progestins (minipill)

• Injectable progestins

• Implantable progestins (Norplant)

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Contraception—cont’d

Emergency contraception

Used within 72 hours of unprotected

intercourse

Three methods available in the United

States

• High doses of estrogen or COCs

• Two days of levonorgestrel

• Insertion of the copper intrauterine device

(IUD)

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Contraception—cont’d

IUD

Small, T-shaped device inserted into the uterine

cavity

Medicated IUDs loaded with either copper or

progestational agent

IUD offers no protection against STIs or HIV

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Fig. 7-14. Intrauterine devices. A, Copper T380A. B, Levonorgestrel-releasing intrauterine

device.

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Contraception—cont’d

Sterilization

Female

• Tubal occlusion

• Tubal reconstruction

Male (vasectomy)

• Tubal reconstruction (reanastomosis)

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Fig. 7-15. Sterilization. A, Uterine tubes ligated and severed (tubal ligation). B, Sperm duct

ligated and severed (vasectomy).

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Fig. 7-16. Use of minilaparotomy to gain access to uterine tubes for occlusion procedures.

Tenaculum is used to lift uterus upward (arrow) toward incision.

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Abortion

Purposeful interruption of pregnancy

before 20 weeks of gestation

Elective

Therapeutic

Contributing factors

Legal and moral issues

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Abortion—cont’d

First-trimester abortion

Surgical (aspiration) abortion

Methotrexate and misoprostol

Mifepristone and misoprostol

Second-trimester abortion

Dilation and evacuation

Prostaglandins

Hypertonic and uterotonic agents

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Key Points

Infertility: inability to conceive and carry a

fetus to term gestation

Infertility affects about 10% to 15% of

otherwise healthy adults

Infertility increases in women older than 35

years

In the United States about one third of

infertility causes are related to female causes,

one third are related to male causes, 20% of

causes are unexplained

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Key Points—cont’d

Common etiologic factors include decreased

sperm production, ovulation disorders, tubal

occlusion, and endometriosis

Reproductive alternatives include: IVFET,

GIFT, ZIFT, oocyte donation, embryo

donation, TDI, surrogate motherhood, and

adoption

Contraceptive methods with various

effectiveness rates, advantages, and

disadvantages are available

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Key Points—cont’d

Women and their partners should choose the

contraceptive method(s) best suited to them

Effective contraceptives are available through

both prescription and nonprescription sources

Concurrent use of spermicides and latex

condoms provides protection against STIs

Tubal ligations and vasectomies are

permanent sterilization methods

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Key Points—cont’d

Induced abortion performed in the first

trimester is safer and less complex

Most common complications of induced

abortion include infection, retained products

of conception, and excessive vaginal

bleeding