Infertility is defined as the inability of a couple to achieve pregnancy after one year of consistent sexual intercourse without using any contraceptive methods.

More specifically, infertility is diagnosed when a couple is unable to conceive despite engaging in regular, unprotected sexual activity during their reproductive years, typically considered to be between 15 and 49 years of age, for a period of at least one year without any contraception.

Types of Infertility

Primary Infertility: This refers to the situation where a couple has never achieved a pregnancy before, despite attempting to conceive. It describes couples who have not been able to establish a pregnancy after one year of trying to conceive through unprotected intercourse.

Secondary Infertility: This type of infertility occurs when a couple has successfully conceived at least once in the past, but is now unable to conceive again, despite not using contraception. This applies even if a previous pregnancy ended in a miscarriage or abortion.

Causes of Infertility

In Males

• Mental Health Issues: Conditions like depression can negatively impact fertility.

• Sperm Issues: Problems with sperm can include the release of immature sperm, abnormal sperm shape, low sperm count, or poor sperm movement (motility).

• Ejaculation Problems: Difficulties or failure to ejaculate can prevent fertilization.

• Heat Exposure: Elevated temperature of the testes, caused by prolonged fever or exposure to excessive heat, can impair sperm production, reducing sperm count, sperm movement, and increasing abnormal sperm forms.

• Hydrocele: An excessive build-up of fluid in the scrotum (hydrocele) can hinder sperm production due to temperature regulation issues and pressure.

• Varicocele: Varicose veins in the scrotum (varicocele) can disrupt blood flow to and from the testes, leading to increased testicular temperature and impaired sperm production. It may also affect ejaculation.

• Medications: Certain drugs, such as amoebicides (used to treat amoebiasis), some antihypertensives like aldomet (methyldopa), and certain diabetes medications, can cause erectile dysfunction.

• Mumps: This viral infection can cause orchitis (inflammation of the testes), potentially damaging sperm production.

• Hormonal Imbalance: Inadequate production of testosterone can lead to the development of immature sperm.

• Sperm Degeneration: Certain substances, like nitrofurantoin (an antibiotic), can cause degenerative changes in sperm.

• Lifestyle Factors: Excessive smoking and alcohol consumption are detrimental to sperm health.

• Obesity: Being overweight or obese can affect hormone balance and sperm quality.

• Retrograde Ejaculation: This condition involves ejaculation occurring backwards into the bladder instead of out of the penis. It can be identified by examining urine after ejaculation.

• Toxic Exposures: Exposure to toxic chemicals or radiation can damage sperm production (spermatogenesis).

• Genetic Factors: Certain genetic conditions can cause infertility.

  • Klinefelter Syndrome: A genetic condition where males have an extra X chromosome (XXY instead of XY). This leads to gynecomastia (breast enlargement), testicular atrophy (shrinking of testes), azoospermia (absence of sperm), and infertility. The testicular atrophy is due to fibrosis in the tubules, replacing sperm-producing tissue.

  • Turner Syndrome: While typically affecting females, genetic variations related to sex chromosomes can also impact male fertility indirectly through complex mechanisms. Classical Turner syndrome primarily relates to females missing or having an abnormal X chromosome (XO instead of XX). This leads to ovarian failure, other physical characteristics, and infertility in females, but is listed here as a genetic factor affecting sex chromosomes broadly.

Causes/Factors in Females

Female infertility causes can be categorized as issues with:

• Defective Implantation

• Endocrine Disorders

• Ovarian Disorders

• Defective Transport

• Physical / Psychological Disorders

• Systemic Disorders

DEFECTIVE IMPLANTATION

• Tubal Blockage: This is a major cause, particularly in regions with high rates of Pelvic Inflammatory Disease (PID). PID, often caused by infections from sexually transmitted infections (STIs) like gonorrhea and chlamydia, or infections after abortion, delivery, or appendicitis, can damage the fallopian tubes. Salpingitis (inflammation of the fallopian tubes) can lead to scarring and blockage, often at the outer end near the fimbriae, but also in the narrow interstitial part of the tube.

  • Ectopic Pregnancy: If the tubes are partially damaged but not completely blocked, fertilization might still occur, but damage to the cilia (tiny hairs lining the tubes) may prevent the fertilized egg from moving to the uterus, resulting in an ectopic pregnancy (implantation outside the uterus).

• Uterine Abnormalities: Some women are born with congenital uterine abnormalities such as no uterus, a bicornuate uterus (heart-shaped), or a uterus didelphys (double uterus).

• Tubal Factors: Beyond PID, other factors can cause tubal blockage, such as adhesions from STIs like gonorrhea.

• Uterine Fibroids: Large uterine fibroids can distort the uterine cavity, creating an irregular surface that interferes with embryo implantation.

• Endometritis: Severe inflammation of the endometrium (uterine lining), also known as uterine synechiae, can impair implantation.

• Intrauterine Adhesions: Adhesions within the uterus can form after procedures like myomectomy (fibroid removal) or over-aggressive uterine curettage.

• Cervical Stenosis: A narrowed or blocked cervix (stenosed cervix) can result from trauma during dilatation and curettage (D&C) or may be congenital. Gynatresia, a very small or blocked vaginal opening, is a related congenital issue.

• Endometriosis: This condition involves endometrium-like tissue growing outside the uterus, such as in the ovaries, fallopian tubes, or abdominal cavity. This tissue responds to hormonal cycles, causing pain, inflammation, scar tissue, and potentially infertility.

• Trichomonas Vaginalis: Evidence suggests that Trichomonas vaginalis infection may be a contributing factor to infertility in some regions.

• Barrier Contraceptive Use: While contraceptives prevent pregnancy, some notes mention a potential link between long-term use of barrier methods (condoms, IUDs, spermicides) and implantation issues, which needs further context and may be indirect or related to other factors. This point might be outdated or require more nuanced interpretation; barrier methods themselves don’t directly cause implantation defects.

• Vaginal and Hymen Issues: Conditions like septate vagina (vaginal septum) and rigid hymen could theoretically impede natural conception.

• Congenital Absence of Fallopian Tubes: Rarely, women are born without fallopian tubes.

ENDOCRINE DISORDERS

• Hormonal Imbalances: Problems involving the hypothalamus, pituitary gland, or ovaries can disrupt the hormonal cascade needed for ovulation and implantation.

  • Hypothalamic Dysfunction: Stress, certain medications (e.g., rauwolfia, phenothiazines, metoclopramide), and extreme weight changes (weight loss or gain) can alter hypothalamic function, affecting dopamine and noradrenaline transmission, which in turn can impact reproductive hormones.

  • Pituitary Tumors: Tumors in the pituitary gland can cause excessive prolactin production (hyperprolactinemia), leading to anovulation. These tumors can be microadenomas or macroadenomas. Elevated prolactin is normal during breastfeeding and causes natural anovulation, but in non-lactating women, it can cause infertility.

  • Thyroid and Adrenal Dysfunction: Abnormal thyroid function (hyperthyroidism or hypothyroidism) or adrenal function (Cushing’s syndrome or congenital adrenal hyperplasia) can also lead to anovulation.

• Age: Fertility naturally declines with age, especially as women approach menopause. Delaying childbearing for career or other reasons can become a factor in infertility.

OVARIAN CAUSES

• Ovarian Malfunction:

  • Resistant Ovary Syndrome: Lack of Follicle-Stimulating Hormone (FSH) receptors in the ovarian follicles prevents the ovaries from responding to gonadotropins, disrupting follicle development.

  • Polycystic Ovary Syndrome (PCOS): Disturbances in the interaction between FSH and follicles, possibly involving abnormal enzyme reactions, can lead to anovulation and the development of multiple cysts in the ovaries (polycystic ovaries). Failure to ovulate results in a lack of secretory changes in the endometrium, and cervical mucus remains thick and hostile to sperm.

• Lack of Eggs or Follicles: Some women may have a congenital absence of eggs or follicles in their ovaries.

• Premature Menopause: Early onset of menopause results in ovarian failure.

• Ovary Damage:

  • Surgical Removal: Accidental removal of an ovary during surgery, or intentional removal in cases of disease.

  • Infection: Infections like mumps oophoritis (inflammation of the ovaries) can destroy ovarian tissue.

  • PID-related Adhesions: Pelvic inflammatory disease can lead to adhesions within the ovaries (similar to Asherman’s Syndrome in the uterus, though “Asherman’s” more typically refers to uterine adhesions).

  • Radiation Exposure: Chronic or excessive exposure to radiation or X-rays can damage eggs.

DEFECTIVE TRANSPORT

• Sperm Allergy/Cervical Hostility: Cervical mucus that is unreceptive or hostile to sperm can prevent sperm from moving through the cervix or even kill sperm. This can be due to infection or the presence of sperm antibodies in the woman’s cervical mucus.

• Vaginal pH: An acidic vaginal pH can be detrimental to sperm motility and survival.

PHYSICAL/ PSYCHOLOGICAL CAUSES

• Physical Obstructions: Conditions that physically prevent the union of egg and sperm in the female reproductive tract.

  • Dyspareunia and Vaginismus: Dyspareunia (painful intercourse, due to psychological or physical reasons) and vaginismus (involuntary muscle spasms making intercourse difficult or impossible) can prevent successful intercourse and conception.

  • Retroverted Uterus: While usually not a direct cause of infertility, a severely retroverted uterus (tilted backwards) may in some cases theoretically affect sperm transport. This is generally considered a less significant factor now.

• Psychological Factors: Stress and depression can disrupt hormonal balance and impact fertility.

• Timing of Intercourse: Incorrect timing of sexual intercourse, missing the fertile window around ovulation, will prevent pregnancy.

SYSTEMIC CAUSES

• Systemic Diseases: Underlying health conditions like Diabetes Mellitus, hypertension, and renal failure can negatively affect fertility in both men and women.

Treatment

Treatment for infertility is directed at the underlying cause.

Prevention

• Smoking Cessation: Stop smoking to improve reproductive health.

• Moderate Alcohol Consumption: Reduce alcohol intake.

• Healthy Diet: Maintain a proper and balanced diet.

• Optimal Timing of Intercourse: Engage in intercourse during the fertile window (around ovulation).

• Stress Reduction: Manage stress and tension.

• Counselling: Seek counseling and support to cope with the emotional challenges of infertility.

• Artificial Insemination: Artificial insemination may be an option in certain cases.

Complications

• Depression: Infertility can lead to depression and emotional distress.

• Divorce: Relationship strain and divorce can be a consequence.

• Extramarital Affairs: In some cultural contexts, infertility may contribute to sexual immorality or extramarital affairs due to societal pressures to have children.

• Polygamy: In some cultures, infertility may lead to polygamy in an attempt to have children through another partner.

Conditions that Should Be Fulfilled for Implantation to Occur

For successful implantation and pregnancy, several conditions are necessary:

1. Partnership: Requires two partners intending to conceive.

2. Unprotected Intercourse: Engage in unprotected sexual intercourse without contraception, with active participation from both partners.

3. Correct Route: Utilize the vagina as the route for intercourse (penis in vagina).

4. Reproductive Age: Both partners should be within reproductive age, generally considered 14 to 49 years for women for this simplified note.

5. Healthy Semen: The male partner needs to release healthy semen containing a sufficient number of normal and motile sperm.

6. Healthy Ova: The female partner must release normal, healthy eggs (ova) from the ovary.

7. Fertilization: The egg must unite with sperm to become fertilized.

8. Implantation: The fertilized egg must implant successfully in the uterus.

NB: The term sterility should be reserved for situations where treatment is impossible to enable conception, such as the complete absence of testes in a man or the absence of a uterus in a woman. Infertility is often treatable.

General Investigation

All couples experiencing infertility should be investigated, although the extent of investigation will vary. Initial interviews should involve both partners.

Comparative Overview: Fertility Investigations

EVALUATION IN WOMEN (FEMALES)

History

1. Menstrual History: Age at first period (menarche) and characteristics of menstrual cycles (length, regularity).

2. Previous Gynecological History: Past contraceptive use and outcomes, history of dilatation and curettage (D&C), salpingectomy (fallopian tube removal), etc.

3. History of Abortions/PID: History of abortions (miscarriages or induced) and any history suggestive of Pelvic Inflammatory Disease.

4. Previous Obstetric History: History of previous pregnancies and the number of children fathered by the current partner.

5. History of Pelvic Infection: Any past pelvic infections.

6. General Health and Nutrition: Overall health status and nutritional status.

7. Age: Age of both partners, noting that female fertility significantly declines after 50 (menopause).

8. Weight: Weight extremes. Being significantly underweight or obese can disrupt ovulation. Obesity can lead to higher levels of estrone compared to estradiol. Being very thin can lead to amenorrhea (absence of menstruation).

9. Sight: Check for visual field defects, which might indicate a pituitary tumor pressing on the optic nerve.

10. Prolactin Check: Assess for signs of excessive prolactin.

11. Hair Distribution: Examine pubic hair and general body hair distribution. Virilization (male-pattern hair growth in women) can indicate high androgen levels.

Vaginal Examination

• Vaginal Normality: Check for vaginal abnormalities through visual examination and potentially ultrasound.

Hormonal Investigations

• Progesterone Levels: In a 28-day cycle, check progesterone levels around day 21 to assess if ovulation occurred.

• Ovulation Confirmation:

  • Serial Ultrasound: Use serial ultrasounds to monitor follicle development and confirm ovulation.

• FSH and LH: Check FSH and Luteinizing Hormone (LH) levels, especially in cases of suspected premature menopause or ovarian failure.

• Hysterosalpingogram (HSG): A procedure to assess tubal patency and uterine cavity shape.

• Post-Coital Test: To assess for sperm-mucus interaction and potential sperm allergy or cervical hostility.

Polycystic Ovary Syndrome (PCOS) is noted as being more common in European populations.

SPECIAL TESTS

• BASAL BODY TEMPERATURE (BBT) CHARTING: The woman takes her oral temperature every morning before getting out of bed and records it. A sustained rise of about 0.5 degrees Celsius in the latter half of the cycle suggests ovulation has occurred. Charting is typically done for 6 months.

• EXAMINATION OF CERVICAL MUCUS: Cervical mucus examined mid-cycle (around ovulation) shows characteristic changes if ovulation is occurring. Ovulatory mucus is clear, copious, and stretchy (spinnbarkeit). When dried, it forms a fern-like pattern under a microscope due to crystallization.

• PROGESTERONE LEVEL BLOOD TEST: A blood sample is taken approximately one week before the expected period (e.g., day 21 of a 28-day cycle). A progesterone level above 20 nmol/L (or equivalent unit) confirms ovulation.

• ENDOMETRIAL BIOPSY (HISTOLOGY): A small sample of the endometrium is taken premenstrually. Histological examination reveals secretory changes in the glands if ovulation has occurred.

• LAPAROSCOPY: A minimally invasive surgical procedure used as a tubal patency test. A dilute methylene blue dye solution is injected through the cervix into the uterus via a cannula. The laparoscope allows visualization of the uterus and fallopian tubes. Patent tubes will fill with dye and spill out of the distal ends. Distal blockage is indicated by no dye spill, while medial blockage is suggested if no dye enters the tubes. Pregnancy must be ruled out before laparoscopy.

• TUBAL INSUFFLATION: An unreliable and less common method where carbon dioxide gas is introduced into the uterus through the vagina. Auscultation is used to listen for gas sounds to assess tubal patency, and an X-ray might follow. This is generally replaced by more accurate methods like HSG and laparoscopy.

• HYSTEROSALPINGOGRAM (HSG): A radiographic procedure where a radio-opaque dye is injected through the cervix into the uterus and fallopian tubes under X-ray guidance. It is performed in the first 5-10 days of the menstrual cycle, after bleeding has stopped but before ovulation. Free spillage of dye from the ends of the tubes indicates patency, while no spillage suggests blockage and potentially the site of blockage.

• POST COITAL TEST (HUHNERS TEST): Performed around ovulation time (1-2 days before ovulation) and 2-8 hours after unprotected intercourse. A sample of cervical mucus is collected from the endocervical canal using a speculum, wire loop, or pipette. The sample is placed on a warm slide and examined under a microscope to assess the number and motility of progressively motile sperm in several high-power fields. A normal result shows a large number of active sperm.

• PROLACTIN TESTS: If prolactin levels are elevated above 800 mU/L (or equivalent unit), computerized tomography (CT) scan of the pituitary fossa is recommended to rule out a prolactin-producing pituitary adenoma.

• ENDOMETRIAL BIOPSY: Typically done 10-12 days after ovulation.

• TRANSVAGINAL ULTRASOUND (TVS): Ultrasound performed through the vagina to visualize pelvic organs.

  • Contraindications: Suspected pregnancy, cervical erosion, pelvic infection, serious heart and lung diseases, menstruation or dysfunctional uterine bleeding (though usually timed outside of menses, bleeding may obscure images).

  • Risks: Rare risks include embolism and ascending infection.

EVALUATION IN MAN (MALE)

1. General Health: Assess for conditions like obesity, Diabetes Mellitus, and hypertension, which can impact fertility.

2. Physical Exam:

   • Hair Distribution and Genitalia: Examine hair distribution and genital development for signs of hormonal imbalances.

   • Undescended Testis: Check for undescended testes (cryptorchidism), which should be corrected surgically before puberty.

   • Breast Enlargement (Gynecomastia): Check for breast enlargement, which could indicate increased estrogen levels.

   • Testes Exam: Palpate testes for size and position. Small or abnormally positioned testes may indicate problems.

3. Hormonal Assessment: Decreased androgen levels can contribute to infertility.

4. Blood Tests: Evaluate FSH and LH levels.

5. Semen Analysis (Sperm Count/Seminal Fluid Analysis): A crucial test. A normal sperm count is generally considered 20 million sperm per milliliter or higher. Counts below 10 million/ml are considered oligospermia and suggest a problem.

   • NORMAL FINDINGS in Semen Analysis:

     • Volume: ≥ 2 ml or 2.5 ml.

     • pH: 7-8 (slightly alkaline).

     • Total Sperm Count: More than 20 million/ml.

     • Liquefaction: Complete within 1 hour (semen should become liquid).

     • Motility: ≥ 50% of sperm with forward (progressive) motility.

     • Morphology: ≥ 30% or more of sperm with normal shape (strict criteria may use different percentages).

     • Concentration: ≥ 20 million/ml.

   • ABNORMAL SEMEN ANALYSIS TERMS:

     • Azoospermia: Absence of sperm in semen.

     • Oligospermia: Low sperm count (less than 20 million/ml, or lower threshold depending on lab criteria).

     • Asthenospermia: Reduced sperm motility.

     • Teratospermia: Increased proportion of sperm with abnormal morphology (shape).

Treatment  General in Women

CHEMOTHERAPY (Medications)

1. For Anovulatory Infertility: To stimulate ovulation, Clomiphene Citrate (Clomid) is often used.

   • Dosage: Typically 50mg daily for 5 days, starting around day 2 of the menstrual cycle or at any time if cycles are absent. If ovulation doesn’t occur, a second course of 100mg daily for 5 days can be given, potentially as early as 30 days after the previous course. Generally, 3 courses of therapy are considered sufficient to assess whether ovulation can be achieved with clomiphene.

   • Mechanism: Clomiphene induces ovulation by stimulating the hypothalamic-pituitary system to release gonadotropins.

   • Key Issue/Caution: Clomiphene treatment can increase the risk of multiple pregnancies (twins, triplets, etc.) because the dose is difficult to precisely adjust and may stimulate multiple follicles to ovulate.

   • Side Effects: Potential side effects include visual disturbances, abdominal discomfort, headache, insomnia, ovarian hyperstimulation syndrome (OHSS), hair loss, breast tenderness, depression, hot flushes, abnormal uterine bleeding, intermenstrual spotting, endometriosis (possible exacerbation), dizziness, nausea and vomiting, and menorrhagia (heavy periods).

2. Tamoxifen: Tamoxifen (similar mechanism to clomiphene, but less commonly used for ovulation induction).

   • Dosage: Typically 20mg daily on days 2, 3, 4, and 5 of the menstrual cycle. The dose can be increased up to 40mg or even 80mg if needed.

3. For Hyperprolactinemic Infertility: Bromocriptine (Parlodel, Lactodel, Dopagon, Brameston) is used to treat infertility caused by high prolactin levels.

   • Mechanism: Bromocriptine inhibits the synthesis and release of prolactin by the pituitary gland.

   • Dosage: Initially 1.25mg at bedtime, gradually increasing to a usual dose of 2.5mg three times a day with food. The dose can be further increased if necessary, up to a maximum of 30mg daily.

   • Side Effects: Common side effects include nausea, headache, nasal congestion, fatigue, dry mouth, diarrhea, constipation, drowsiness, hypotension, dizziness, and abdominal cramps.

   • Drug Interactions:

     • Erythromycin may increase bromocriptine plasma concentration, raising the risk of toxicity.

     • Antipsychotics, domperidone, and metoclopramide can antagonize the effects of bromocriptine.

4. Luteinizing Hormone-Releasing Hormone (LHRH) Administration: In patients with hypothalamic dysfunction, pulsatile LHRH administration can be used to induce a pituitary response and stimulate ovulation.

   • Dosage: Typically 10-25 micrograms released every 90 minutes using a syringe pump. Administered intravenously or subcutaneously.

   • Duration: Treatment is continued throughout the menstrual cycle.

   • Success Rate: Reported success rates are in the range of 60-70%.

5. Tubal Blockage Treatment:

   • Surgery: Surgery may be attempted to unblock fallopian tubes and remove adhesions. Success rates are often low.

     • Salpingolysis: Surgical division of peritubal adhesions (adhesions around the tubes), particularly at the ampullary ends, to restore tubal function.

     • Salpingostomy: Surgical creation of a new opening in the fallopian tube when the fimbriae are closed or damaged.

     • Tubal Anastomosis and Repair: Typically performed when the blockage is in the isthmus of the fallopian tube. The blocked segment is removed, and the cut ends of the tube are surgically reconnected (anastomosed).

     • Tubal Re-implantation: If the blockage is in the interstitial portion (part closest to the uterus), the tube may be divided near the uterus, the blocked segment cored out, and the healthy tube segment re-implanted into the uterus.

6. Synthetic Human Chorionic Gonadotropin (hCG) Hormone: hCG has a similar action to LH and can be used to trigger ovulation. Timed intercourse around the time of hCG administration is recommended.

7. Human Menopausal Gonadotropin (hMG – e.g., Pergonal) or Pure FSH (e.g., Metrodin): Used if clomiphene fails to induce ovulation. These are more potent gonadotropins and carry a higher risk of multiple pregnancies and ovarian hyperstimulation.

8. Correction of Uterine, Cervical, or Vaginal Problems: Surgical or medical correction of any identified issues such as uterine fibroids (myomectomy), cervical stenosis, or vaginal abnormalities.

Treatment in Male

1. Human Gonadotropin Therapy/Clomiphene Citrate: Clomiphene citrate can be given to men to stimulate sperm production by increasing gonadotropin release.

2. Testosterone Therapy: Testosterone may be given to improve sexual desire, but it is contraindicated in cases of impaired spermatogenesis, as it can suppress sperm production further. Testosterone’s role in male infertility treatment is complex and depends on the specific cause; it’s not always the right treatment and can sometimes worsen sperm production if used inappropriately.

3. Surgical Measures:

   • Relief of Reproductive Tract Obstruction: Surgery to correct any blockages in the reproductive tract.

   • Inguinal Hernia Repair: Repair of an inguinal hernia if present.

   • Varicocele Surgery: Surgical ligation (tying off) of the internal spermatic vein to treat varicocele.

Other considerations for both partners

In Vitro Fertilization (IVF)

• IVF History: Robert Edwards received the Nobel Prize in Physiology or Medicine for the development of IVF, which was developed in 1978.

• IVF Requirements: IVF requires healthy eggs, sperm capable of fertilization, and a uterus capable of sustaining pregnancy.

• IVF Process: IVF is a treatment for women unable to conceive naturally. An egg is retrieved (from the woman or a donor), fertilized with sperm (from the partner or a donor) in a lab (“test tube”), and the resulting embryo(s) are implanted into the uterus.

• Multiple Pregnancy Risk in IVF: IVF often results in multiple pregnancies (twins, triplets, etc.) because multiple embryos are often transferred to increase the chance of implantation.

• IVF Combinations: IVF can be combined with surrogacy (egg donation) and preimplantation genetic diagnosis (PGD) to screen embryos for genetic disorders before implantation. PGD is similar to preimplantation genetic haplotyping.

• Early IVF Method: Early IVF involved collecting eggs from the fallopian tubes or uterus after natural ovulation, mixing them with sperm, and re-inserting them into the uterus. Current IVF techniques are more advanced.

ADDITIONAL TECHNIQUES TO ENHANCE IVF SUCCESS:

1. Ovarian Hyperstimulation: Using Gonadotropin-Releasing Hormone (GnRH) agonists and FSH to stimulate the ovaries to produce multiple eggs for retrieval.

2. Ultrasound-Guided Transvaginal Oocyte Retrieval: Eggs are retrieved directly from the ovaries using an ultrasound-guided needle inserted through the vagina. An injection of Human Chorionic Gonadotropin (hCG) is given as a “trigger shot” to mimic the LH surge and induce final egg maturation. Egg retrieval is typically done 34-36 hours after the hCG trigger, before follicle rupture (ovulation), which is expected around 38-40 hours post-hCG. Caution is needed to prevent ovarian hyperstimulation syndrome (OHSS).

3. Egg and Sperm Preparation: Sperm washing is used to remove seminal fluid, purify sperm, and potentially remove microbes and viruses (e.g., HIV).

4. Embryo Selection: Embryos are selected for transfer to the uterus based on their quality and developmental stage.

5. Intracytoplasmic Sperm Injection (ICSI): ICSI may be used alongside IVF, especially for male factor infertility (sperm quality issues, difficulty penetrating the egg, very low sperm count). ICSI involves directly injecting a single sperm cell into an egg cell before implantation.

Surrogate Parents

• Surrogacy: If a woman lacks a uterus, her eggs can be fertilized with her partner’s sperm (or donor sperm) via IVF, and the resulting embryo implanted into a surrogate mother’s uterus. The surrogate carries the pregnancy and, after birth, hands over the child to the intended parents.

Adoption of Children

• Adoption Option: Couples unable to conceive may consider adoption and can apply to adoption centers.

Artificial Insemination by Donor (AID)

• AID for Male Infertility: Used when the male partner is infertile. Semen from a fertile donor is used for artificial insemination of the potentially fertile female partner.

NURSING DIAGNOSES

1. Anxiety and Fear: Related to unknown procedures, treatment, and outcomes, as evidenced by patient verbalization of worry and uncertainty.

2. Low Self-Esteem: Related to inability to conceive, as evidenced by low mood, negative self-perception, and social withdrawal.

3. Knowledge Deficit (Ovulation, Pregnancy, Sexual Relationship): Related to lack of information about ovulation, conception, and healthy sexual practices for fertility, as evidenced by inaccurate statements or questions.

4. Knowledge Deficit (Sexual Anatomy/Physiology, Infertility Causes): Related to lack of understanding of reproductive anatomy, physiology, and the causes of infertility, as evidenced by verbalizing misconceptions or seeking basic information.