Subfertility: Nursing Assessment and Management

Subfertility is a workup, not a diagnosis you make at the bedside. Both partners get assessed, because the cause sits with the man, the woman, or both. Your job is to gather an accurate history, prepare the couple for the tests, and support them through a process that is as emotionally loaded as it is clinical.

What Is Subfertility?

Subfertility, often called infertility, is difficulty conceiving despite regular unprotected intercourse over an extended period, typically one year or more. Primary subfertility means there were no previous conceptions. Secondary subfertility means the couple conceived before but cannot now.

Male Subfertility Factors

Inadequate Sperm Count

Sperm count is the number of sperm in each ejaculation. The normal count is 20 million sperm per milliliter of seminal fluid, with 50 million in a single ejaculation. At least 50% should be motile and at least 30% should be of good shape and form. Prolonged sitting jobs and driving can raise scrotal heat and lower the count. Cryptorchidism and varicocele affect production, as do testicular trauma, testicular surgery, and endocrine imbalances.

Impaired Sperm Motility

Prostate infections alter seminal fluid composition and reduce motility. Men who have had a vasectomy develop an autoimmune reaction that immobilizes sperm.

Obstruction

Inflammation along the sperm pathway, such as mumps orchitis or epididymitis, obstructs travel. Pressure from tumors, including benign prostatic hypertrophy, interferes with transport.

Ejaculation Problems

Psychological stress can cause erectile dysfunction or impotence, the inability to achieve an erection and ejaculate. Premature ejaculation before penetration also disrupts sperm deposition.

Female Subfertility Factors

The female factors mirror the male ones but cover more dangerous ground.

Anovulation

Genetic abnormalities such as hypogonadism or Turner's syndrome leave no ovaries to produce egg cells. Hormonal imbalances such as hypothyroidism disrupt the ovary-hypothalamus-pituitary axis and block egg production. Nutrition, weight, and exercise affect ovulation, largely through raised blood glucose that disturbs FSH and LH production and leads to ovulation failure. Easy-to-digest carbohydrates, excess protein, and saturated fats reduce fertility. Stress interferes with GnRH secretion and lowers LH and FSH. The most common cause of anovulation is polycystic ovary syndrome, where the ovary overproduces testosterone, suppresses FSH and LH, and the woman ovulates only a few times per year.

Tubal Transport Problems

Adhesion or scarring of the fallopian tubes, from prior tubal ligation or salpingitis, is a main cause. Pelvic inflammatory disease scars and can constrict the tubes if left untreated.

Uterine Problems

Uterine tumors can block the embryo's implantation site. Endometriosis, where displaced endometrium regurgitates and proliferates, impedes implantation. Decreased estrogen and progesterone from the ovary leaves the endometrium underformed and interferes with embryo growth.

Cervical Problems

An infected cervix produces mucus too thick for sperm to penetrate. Scar tissue from a previous D and C also impairs fertility.

Vaginal Problems

Vaginal infection raises pH and destroys sperm motility. Sperm-agglutinating antibodies in some women immobilize and kill sperm in the vaginal environment.

Assessment

Assess alcohol, drug, and tobacco use, and any past radiation treatment. Review current illnesses, especially endocrine disease, plus occupation and work habits. Ask about sexual practices, frequency, and any failed ejaculations, and about past and present contraception. Note any children from previous relationships, and assess the current health of the reproductive system.

Diagnosis

Confirming subfertility takes several tests.

Semen Analysis

After 2 to 4 days of abstinence, the man ejaculates by masturbation into a clean, dry specimen cup. Examination takes at least 1 hour while the sperm are counted. The normal count is 20 million spermatozoa per milliliter of seminal fluid. Repeat the analysis after 2 to 3 months, since spermatogenesis is continuous and new sperm mature in 30 to 90 days.

Sperm Penetration Assay

Tests whether the man's sperm can reach and penetrate an ovum. With IVF, poorly motile sperm can be injected directly into the ovum.

Ovulation Monitoring

The least expensive fertility test for women. She records her BBT daily for four months, taken before she gets up and before any activity, noting anything that affects the reading. During ovulation the temperature dips slightly, then rises but not above her normal level, and holds there for almost 10 days, or 3 to 4 days before the next menstrual flow. If the rise does not last the expected time, a luteal-phase defect is diagnosed.

Ovulation Determination Test Kit

Over-the-counter kits detect the LH surge just before ovulation. She dips the strip into mid-morning urine and reads the color change against the manufacturer's instructions.

Tubal Patency

Sonohysterography is an ultrasound of the uterus: the uterus is filled with sterile saline, then a vaginal transducer is inserted to inspect it. It is minimally invasive and can be done anytime in the cycle. Hysterosalpingography inspects the fallopian tubes using a radiopaque medium and is done after menstrual flow to avoid pushing menstrual debris up the tube. Contraindications are vaginal, cervical, and uterine infections.

Implementation

Management follows the assessment data. Correct underlying problems first, and the provider discusses the realistic chances of conception.

Correction of the Underlying Problem

To raise sperm count and motility, the man refrains from coitus for 7 to 10 days at a time. Lifestyle changes help: avoid prolonged sitting and hot baths, and wear loose clothing.

Reduction of Infection

Treat infection by the organism on culture. For trichomonal infection, Metronidazole can be teratogenic early in pregnancy, so caution the woman if the couple suspects pregnancy.

Hormone Therapy

GnRH is used for disturbed ovulation. Clomiphene citrate stimulates ovulation. Human menopausal gonadotropins stimulate ovarian follicular growth.

Surgery

Intrauterine insemination is the most common surgical route today because it most often yields a viable pregnancy. Tumors interfering with fertility can be removed, such as myomectomy for a myoma. Diathermy or steroid administration can correct tubal insufficiency from inflammation. Laparoscopy or laser surgery can remove peritoneal adhesions or nodules.

Therapeutic Insemination

Therapeutic insemination instills sperm into the reproductive tract so the woman can conceive. Intracervical insemination places sperm in the cervix; intrauterine insemination places it directly in the uterus. Therapeutic insemination by husband uses the husband's sperm; therapeutic donor insemination uses a donor's. It is typically used when the man has a low count or poor motility, or the woman has reproductive factors interfering with fertility. She first pinpoints her ovulation day by BBT, cervical mucus, or a test kit; the day after, sperm are injected into the cervix with a cervical-cap-like device or instilled directly into the uterus.

In Vitro Fertilization

One or more oocytes are aspirated and fertilized by sperm in the laboratory, outside the body. It suits men with a low count or women with fallopian tube abnormalities. She is given an ovulation-stimulating agent first, and the ovaries are scanned by ultrasound daily from the 10th day of the cycle to track follicle development. Once a follicle matures, hCG is injected to trigger ovulation within 39 to 42 hours. The oocyte is aspirated, mixed with sperm, and incubated. The first cell division occurs 40 hours after fertilization.