Infertility Nursing CE Course

nd repeated exposure of the genitals to high temperatures. Some medical conditions can also contribute to male infertility, including a history of hernia repair, undescended testicles, prostatitis, a previous or current STI, or contracting mumps after puberty. An obstruction can develop within the ejaculatory ducts or seminal vesicles, causing azoospermia or inhibiting semen from being ejaculated. The testicles may fail to produce sperm due to varicoceles or damage to the sperm-producing cells following chemotherapy. Certain hormones regulate sperm production; therefore, hormonal imbalances or dysfunction can affect sperm production. Even if a person’s body produces sperm, normal morphology and motility are needed for the sperm to traverse the female reproductive tract (Anawalt, 2024b; Leslie et al., 2024; WHO, 2024).

Patients can make lifestyle changes to decrease the risk of infertility and increase fertility. These changes include the following (Practice Committee of the ASRM and the Practice Committee of the Society for Reproductive Endocrinology and Infertility, 2022; Resolve: The National Infertility Association, n.d.-a).

• Address mental health concerns. Depression and significant stress can negatively affect the hormones involved in ovulation and sperm production; implement self-care activities and seek professional intervention if needed.
• Minimize environmental exposures. Avoid hot tubs, jacuzzi tubs, and saunas, as extended exposure to high heat affects sperm production. In addition, chemicals and pollutants should be avoided in both the environment and the workplace.
• Use protection. Use a condom when having intercourse to prevent STIs leading to infertility.
• Quit smoking. Smoking can decrease sperm production in males and lead to infertility in females; there are many benefits to quitting smoking, including an increase in fertility.
• Decrease alcohol, recreational drugs, and caffeine intake. Having as few as five alcoholic drinks per week can decrease fertility; females should be even more cautious about alcohol consumption when engaging in unprotected intercourse, as they could become pregnant without knowing. Recreational drugs and caffeine can also decrease fertility.
• Maintain, or obtain, a healthy body weight. Body fat levels that are 10% to 15% above or below average can affect fertility. Being overweight can result in too much estrogen, which can affect the menstrual cycle. Being underweight or diagnosed with an eating disorder (e.g.,  anorexia nervosa or bulimia) may result in amenorrhea. Athletes, such as marathon runners and dancers, may also have irregular cycles and, therefore, difficulty conceiving.
• Consume a well-balanced diet. People may experience infertility due to deficient vitamin B12, zinc, iron, and folic acid (e.g., due to absorption issues or poorly planned vegan or vegetarian diets). Supplementation may be needed after consulting an HCP for testing.
• Conceive earlier in life. Although age is not a modifiable risk factor, conceiving earlier in life, when possible, can increase the chances of conceiving without the need for intervention.

 

Diagnostics/Testing

Females

According to the ASRM, fertility testing is recommended for patients who have not become pregnant after 12 months of trying to conceive (TTC). Evaluation at 6 months is recommended when an individual is over the age of 35 or those with known concerns that could make conception more difficult (ASRM, 2023b; Practice Committee of the ASRM, 2021). Evaluation of infertility in females should start with a thorough history, including the following.

• Duration of infertility
• Menstrual history (cycle length and characteristics)
• Medical, surgical, and gynecologic history (thyroid disease, hirsutism, pelvic or abdominal pain, dysmenorrhea)
• Obstetric history (adverse outcomes during a prior pregnancy)
• Sexual history (sexual dysfunction and frequency and timing of sex)
• Family history (family members with infertility, congenital disabilities, or genetic mutations)
• Personal or lifestyle history (occupation, stress, exercise, changes in weight, alcohol, smoking, or substance use) (Kuohung & Hornstein, 2024b)

Anovulation is the most common cause of female infertility. Initial testing for infertility in females includes luteinizing hormone (LH) detection, ovarian reserve testing, a transvaginal ultrasound, and blood tests. Ovulation predictor kits detect the rise in LH in urine that occurs 1 to 2 days before ovulation. Peak fertility starts the day of the LH surge and continues for the next two days. Ovarian reserve testing determines whether a patient can produce healthy eggs and how well the ovaries respond to hormonal signals. A blood sample is taken on cycle day 3 to test for follicle-stimulating hormone (FSH) to evaluate the ovarian reserve. A transvaginal ultrasound can be completed to determine an antral follicle count, reflecting the number of follicles or egg sacs present early in the menstrual cycle. Other blood tests may include estradiol, anti-Müllerian hormone (AMH), inhibin B, thyroid-stimulating hormone (TSH), prolactin, and progesterone levels (ASRM, 2023b; Practice Committee of the ASRM, 2021).

Because tubal blockage is another common cause of infertility, HCPs should assess the fallopian tubes for any anomalies. The following tests and procedures can determine the patency of the fallopian tubes and uterus: a hysterosalpingogram, sonohysterography, a transvaginal ultrasound, hysteroscopy, or laparoscopy. A hysterosalpingogram (HSG) is an x-ray performed using iodine contrast to determine the presence of blocked fallopian tubes or an unexpected uterine cavity shape. The iodine contrast is injected through a catheter inserted into the cervix, filling the uterus and fallopian tubes. If the tubes are open, the contrast dye will spill out. After filling the uterus with saline, a sonohysterography uses a transvaginal ultrasound to detect intrauterine problems such as endometrial polyps and fibroids. A transvaginal ultrasound allows HCPs to visualize the uterus and ovaries for structural anomalies such as fibroids and ovarian cysts. A hysteroscopy is a surgical procedure in which the HCP passes a lighted telescope (hysteroscope) through the cervix to diagnose anomalies within the uterine cavity, such as polyps, fibroids, and adhesions. Laparoscopy is a surgical procedure in which the HCP inserts a laparoscope through the abdominal wall into the pelvic cavity to evaluate for endometriosis, pelvic adhesions, and other anomalies, such as the shape of the reproductive organs. Although laparoscopy is minimally invasive, it is only used for fertility testing if less invasive testing is inconclusive (ASRM, 2023b; Kuohong & Hornstein, 2024b; Practice Committee of the ASRM, 2021).

Males 

Males with infertility rarely have a cause that can be identified. Diagnosis and testing processes for male infertility consist of a thorough history and physical examination, a semen analysis, lab work including an endocrine screening, imaging focused on accessory glands and ducts, and genetic testing. The first diagnostic step should be to complete a thorough history and physical examination focusing on potential causes of infertility, such as sexual development history (e.g., any problems with testicular descent), chronic illness, a history of significant head trauma (due to changes in the brain affecting sexual function and hormone production following head trauma), infections such as mumps or STIs, past surgical procedures including inguinal hernia repairs or a vasectomy, drug use and exposure to environmental toxins, past radiation or chemotherapy, and sexual health (e.g., libido, ability to achieve or maintain an erection, frequency of intercourse, and any previous fertility assessment results). Next, the external genitalia should be assessed for incomplete development, absence of the vasa deferentia, epididymal thickening, and decreased testicular size, which can determine seminiferous tubule volume. Then, a semen sample provided after 2 to 7 days of ejaculatory abstinence is analyzed for volume, pH, immature germ cells, debris, leukocyte count, and sperm characteristics (concentration, motility, morphology). The sample should be obtained in the clinic; however, it can be obtained at home and brought to the clinic. If the semen sample results show severe oligozoospermia (low sperm count) or azoospermia (no sperm present), further endocrine testing should be completed. Endocrine testing for males includes total testosterone, LH, and FSH. Serum testosterone levels should be monitored between 8 AM and 10 AM for the most accurate results. If the patient’s physical assessment and lab results do not suggest a reason for the low sperm count, a scrotal and transrectal ultrasound can be performed to determine if there is a blockage of the ejaculatory duct (Anawalt, 2024a; Leslie et al., 2024).

 

Treatments

Females 

Once the cause of female infertility is identified, a specific treatment can be initiated. There are treatments designed specifically for anovulation, starting with weight management. Because overweight or underweight patients are more prone to ovulatory dysfunction, attaining a healthy weight can normalize ovulation. Some patients need ovulation-inducing medications to initiate ovulation. The first medication used is clomiphene citrate (Clomid, Serophene), a selective estrogen receptor modulator (SERM) containing estrogen antagonists and agonists that increase gonadotropin release. Potential side effects of clomiphene citrate (Clomid, Serophene) include hot flashes, nausea, headaches, blurred vision, depression, mood swings, and thick, dry cervical mucus. Overstimulation of the ovaries may also occur, leading to ovarian cysts and pelvic discomfort (American Pregnancy Association, n.d.; Kuohung & Hornstein, 2023; Walker & Tobler, 2022).

Another option for ovulatory dysfunction is aromatase inhibitors, a class of medications used in postmenopausal patients to stop estrogen production during breast cancer treatment. Examples of aromatase inhibitors include letrozole (Femara), anastrozole (Arimidex), and exemestane (Aromasin). Aromatase inhibitors are an alternative option for patients who experience adverse effects with clomiphene citrate (Clomid, Serophene). Aromatase inhibitors have some benefits over clomiphene citrate (Clomid, Serophene), such as producing fewer follicles, minimizing the chance for a multiple gestation pregnancy, and reducing antiestrogen side effects. Aromatase inhibitors and gonadotropins have become more popular as ovarian-stimulant drugs; however, the US Food and Drug Administration (FDA) has not yet approved aromatase inhibitors for use in infertility (American Pregnancy Association, n.d.; Kuohung & Hornstein, 2023; Walker & Tobler, 2022).

Insulin-sensitizing agents such as metformin (Glucophage) are used for patients with infertility related to insulin resistance. Metformin (Glucophage) is commonly used in patients with PCOS due to the insulin resistance associated with this condition. Using metformin (Glucophage) to correct hyperinsulinemia can increase menstrual cyclicity and promote spontaneous ovulation. Side effects of metformin (Glucophage) include pyrosis, nausea and vomiting, bloating, flatulence, constipation or diarrhea, lactic acidosis, and liver dysfunction. In addition, patients with PCOS may need to undergo laparoscopic ovarian diathermy (also referred to as laparoscopic ovarian drilling [LOD]) to destroy a portion of the ovaries with electrocautery or a laser laparoscopically while the patient is under general anesthesia. This destruction of a part of the ovaries can decrease testosterone production, increasing the regularity of ovulation. Due to the invasive nature of the procedure and the risks involved, LOD should only be used when other treatment options have failed. Risks include complications from general anesthesia, surgical site infection, bleeding from the incision site or internal bleeding, injury to internal organs or blood vessels, and the creation of adhesions (or scarring). If all treatment options are exhausted, and the patient is still unable to conceive, then assisted reproductive technology (ART) is considered (American Pregnancy Association, n.d.; Kuohung & Hornstein, 2023; Walker & Tobler, 2022).

Gonadotropins directly stimulate the ovaries and elicit follicle growth. They are used for patients who have not ovulated or conceived following treatment with clomiphene citrate (Clomid, Serophene) or insulin-sensitizing agents. They are also indicated in cases of hypopituitarism or hypothalamic amenorrhea. Gonadotropins contain either FSH or LH individually or in combination. Unlike other fertility medications, gonadotropins must be administered by intramuscular (IM) injection. There is a risk of multiple gestation and premature delivery with gonadotropin use. Bromocriptine (Parlodel) or cabergoline (Dostinex) are dopamine agonists used as first-line treatment for patients with hyperprolactinemic anovulation because they reduce the amount of prolactin released by the pituitary gland. Hyperprolactinemia inhibits the release of LH and FSH, leading to the disruption of ovulation. Side effects of bromocriptine (Parlodel) and cabergoline (Dostinex) include nausea and vomiting, nasal congestion, dizziness, fainting, and hypotension. Urofollitropin (Fertinex) is an injectable form of a highly purified FSH administered by an HCP. It is utilized with human chorionic gonadotropin (hCG) during ART treatment in patients with healthy ovaries. Urofollitropin (Fertinex) is also used in patients with PCOS who are unable to conceive following clomiphene citrate (Clomid, Serophene) treatment. Side effects of urofollitropin (Fertinex) include abdominal or pelvic pain, bloating, and headache (American Pregnancy Association, n.d.; Fauser, 2024; Kuohung & Hornstein, 2023).

              Patients whose infertility is due to tubal disorders or adhesions have different treatment options. The first-line treatment for bilateral tubal obstruction is in vitro fertilization (IVF). Surgical reconstruction may help with proximal or distal bilateral tube obstruction in those who decline to undergo IVF or do not have access to IVF. There must be a normal uterine cavity and an ability to ovulate to be a candidate for surgical reconstruction. Surgical reconstruction involves resecting obstructed portions of the fallopian tube or threading a catheter through the fallopian tube to remove the blockage. Surgical intervention is not recommended for patients over 39, those with extensive adhesions, or those with both proximal and distal bilateral obstruction. If the procedure is successful, further reproductive intervention is typically not needed, and natural conception can occur in the future (DiPaola, 2021; Kuohung & Hornstein, 2023; Walker & Tobler, 2022).

 

Males 

Addressing male infertility focuses on treating the underlying cause. Surgery can correct anatomic anomalies, blockages, varicoceles, or damage to the reproductive system. Medication can correct hormone imbalances or erectile dysfunction. Clomiphene citrate (Clomid, Serophene) increases natural testosterone levels and triggers the pituitary gland to produce more LH and FSH, improving sperm count, morphology, and motility. Side effects include irritability, acne, pectoral muscle tenderness, and the acceleration of prostate cancer growth if already present. Due to this risk, a thorough prostate cancer screening should be completed before initiating clomiphene citrate (Clomid, Serophene) for male infertility. In those that do not respond to clomiphene citrate (Clomid, Serophene) treatment, hCG or human menopausal gonadotropin (HMG) injections may be used. HCG and HMG are considered second-line treatment options due to their availability as injectable only, although they have the same side effects as clomiphene citrate (Clomid, Serophene). Anastrozole (Arimidex) is used in patients with higher-than-average estradiol levels and lower-than-normal testosterone levels to balance hormone levels and improve sperm count, morphology, and motility. Side effects include joint pain, stomach pain, nausea, diarrhea, edema, and increased risk for fractures. These side effects are less common when anastrozole (Arimidex) is used short-term (Anawalt, 2024c; Leslie et al., 2024; National Institute of Child Health and Human Development [NICHD], 2021).

Conception Technology

 

Intrauterine Insemination

Intrauterine insemination (IUI) involves the placement of sperm into an ovulating uterus. This procedure is most effective for partners with low sperm counts or motility, who cannot achieve an erection, or who have retrograde ejaculation; females with thick cervical mucus, scarring, or cervical defects; those unable to have sexual intercourse; and LGBTQ+ couples. Ovulation-stimulating drugs such as clomiphene citrate (Clomid, Serophene), gonadotropins, or urofollitropin (Fertinex) are often used in conjunction with IUI since the insemination procedure must be performed at the time of ovulation. Urine, blood tests, and ultrasounds are used to predict ovulation, which usually occurs within 24 to 48 hours of an LH surge or after injection of hCG. The sperm used in the procedure can be from either a third-party donor or a male with healthy sperm. The sample of sperm from either source goes through a separation process in which the motile sperm are selected and concentrated. This concentrated sample is then “washed” of any toxins that may cause an adverse reaction once introduced into the uterus. Once the sperm sample is ready, it is introduced directly into the uterus via a small catheter inserted through the cervix. The success rate of IUI depends on the cause of the infertility, whether ovulation-inducing medications were used, and the age of the patient being inseminated. Success rates of 20% per cycle can be achieved when performed monthly (Ginsburg, 2023; NICHD, 2024; Resolve: The National Infertility Association, n.d.-b).

 

Assisted Reproductive Technology (ART) 

ART includes any fertility treatment that involves handling eggs and sperm outside of the body. First, mature eggs are extracted and combined with sperm in a laboratory. The fertilized eggs are then returned to the uterus for implantation, frozen, or donated and used to impregnate another patient (CDC, 2024a). Three different types of ART are available (CDC, 2024c; Salem, 2024).

• IVF is the most common type of ART. IVF involves combining an egg and sperm in a laboratory to create an embryo. This is typically accomplished using conventional fertilization, during which a mature egg is placed into a petri dish with many sperm, allowing the sperm to fertilize the egg without additional intervention. After 3 to 5 days, the embryo is either transferred into the female’s uterus or frozen for later use. When an embryo is frozen, thawed, and then implanted, it is known as a frozen embryo transfer (FET).
• Intracytoplasmic sperm injection (ICSI) is a type of IVF used in male infertility during which a single sperm is injected into a mature egg.
• Zygote intrafallopian transfer (ZIFT) and gamete intrafallopian transfer (GIFT) are rarely used in the US. With ZIFT, an embryo is transferred into the fallopian tube instead of the uterus. In GIFT, the sperm and a mature egg are transferred into the fallopian tube, where fertilization occurs.  

ART can involve the patient’s sperm and/or eggs or use donated sperm and/or eggs from other individuals. Donated sperm and eggs are used when patients cannot produce their own, or if there is a risk of a genetic disorder being passed to their offspring. Donated embryos can also be used for transfer. In some cases, patients with functioning sperm and eggs opt for ART if the female is not medically well enough to become pregnant and carry a child or does not have a uterus. In this case, the embryo created from the patient’s egg and sperm is transferred into the uterus of a gestational carrier. Each year in the US, all fertility clinics that handle either eggs or embryos report how many ART cycles were performed and the outcomes of each cycle. The CDC’s 2022 Fertility Clinic Success Rates Report shows that 435,426 ART cycles were performed, resulting in 94,039 live births. Of the cycles performed, 184,423 were banking cycles where the eggs or embryos were frozen for future use. Over the last decade, the use of ART has doubled; approximately 2.1% of all infants born in the US each year are conceived using ART (CDC, 2024a; CDC, 2024d; Salem, 2024).

             

IVF 

IVF has been used to avoid passing a hereditary illness to potential offspring, decrease the transmission of HIV/AIDs, and overcome barriers experienced by older patients and those taking medications or undergoing procedures that compromise their ability to reproduce. Several medications are used in a typical IVF cycle, depending on the protocol. Gonadotropin-releasing hormone (GnRH), produced in the pituitary gland, indirectly stimulates ovarian function. GnRH agonists stimulate the pituitary to release stored gonadotropins. The most used GnRH agonist is leuprolide acetate (Lupron). Adverse effects include hot flashes, headaches, painful intercourse, mood swings, and insomnia. GnRH antagonists are used to suppress hormone production, making ovarian stimulation easier to regulate. Exogenous gonadotropins are then administered to stimulate the production of multiple oocytes, replacing endogenous LH and FSH. HCG stimulates the oocytes’ final maturation and progesterone production from an ovary after egg retrieval (Choe & Shanks, 2023; Society for Assisted Reproductive Technology [SART], n.d.).

Risks

According to the American College of Obstetricians and Gynecologists (ACOG) committee opinion, reaffirmed in 2024, the most common complication following ART is a multiple gestation pregnancy. This complication can be avoided or minimized by limiting the number of embryos transferred into the uterus. Conceiving through ART can increase the risk of premature delivery and low birth weight and cause ovarian hyperstimulation syndrome, which causes the ovaries to become swollen and painful. Symptoms can last up to a week and include abdominal pain, bloating, diarrhea, nausea, and vomiting. This syndrome is directly related to hCG and other injectable ovulation-inducing medications. In addition, conception always conveys the risk of miscarriage. The risk of miscarriage with ART is 23%, similar to pregnancies conceived naturally. There is a 2% to 5% risk that the embryo implants outside the uterus, resulting in an ectopic pregnancy. There are also risks and side effects from the egg-retrieval procedure, such as bleeding, infection, and damage to the bowel, bladder, or blood vessels. Many patients experience bloody or clear discharge following embryo transfer, along with breast tenderness, bloating, cramping, and constipation (ACOG, 2016; Salem, 2024).

References

American College of Obstetricians and Gynecologists. (2016). Perinatal risk associated with assisted reproductive technology. Committee opinion 671. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2016/09/perinatal-risks-associated-with-assisted-reproductive-technology

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