InfertilityPresented by: Ritchie, A., Savalle, O., Shammo, A., Szwast, L.,

Tomljenovic, J., & Walk, J.

Oakland University

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(Mayo Clinic, 2014)

Facts About InfertilityWhat is it: Infertility is when you cannot get pregnant after having

unprotected, regular sex for six months to one year, depending on your age

Causes: Infertility may be due to single cause in either you or your partner, or a combination of factors that may prevent a pregnancy from occurring or continuing

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MALE FEMALE

Abnormal sperm production or function Ovulation disorders

Problems with the delivery of sperm Uterine or cervical abnormalities

Overexposure to certain chemicals and toxins Fallopian tube damage or blockage

Damage related to cancer Endometriosis & primary ovarian insufficiency

Pelvic adhesions

Symptoms: The main symptom of infertility is not getting pregnant. May not have any other symptoms

Risk factors: Tobacco/Alcohol use; age; exercise issues; obesity; anorexia

How to diagnose:

(Mayo Clinic, 2014)

Facts About Infertility

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MALE FEMALE

Semen analysis Ovulation testing

Hormone testing Hysterosalpingography

Ultrasound Hormone testing

Genetic testing Genetic testing

Biopsy Imaging testing

Blood tests

Is it common? Yes. About 6% of married women 15-44 years of age in the United States are unable to get pregnant after one year of unprotected sex

Also, about 12% of women 15-44 years of age in the US have difficulty getting pregnant or carrying a pregnancy to term, regardless of marital status (impaired fecundity)

Number of women ages 15-44 with impaired fertility/fecundity: 6.7 million (10.9%)

Number of married women ages 15-44 that are infertile (unable to get pregnant after at least 12 consecutive months of unprotected sex with husband): 1.5 million (6.0%)

Number of women ages 15-44 who have ever used infertility services: 7.4 million

Why is it important: It is a common problem that can create a multitude of other issues within a family (Domino Effect)

(Center for Disease Control and Prevention, 2016; Roberson, 2015)

Prevalence and Incidences of Infertility

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Dependent on: Cause, infertile length, age, partner’s age, and personal preferences

Unfortunately, some causes of infertility can’t be corrected. However, a woman may still become pregnant with assisted reproductive technology (ART). These infertility treatments involve significant financial, physical, psychological, and time commitment

Assisted reproductive technology (ART) fast facts: Each year thousands of babies are born in the US as a result of ART. The success rate of ART is lower after age 35

Multiple types of ART: In vitro fertilization (IVF)

Zygote intrafallopian transfer (ZIFT)

Gamete intrafallopian transfer (GIFT)

Intracytoplasmic sperm injection (ICSI)

(Mayo Clinic, 2014; Center for Disease Control and Prevention, 2016)

Treatment Options

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Nutrition

Weight loss

Scrotal temperature

Water-soluble lubricants

Condoms to lower female antisperm antibodies

(Lowdermilk, Perry, Cashion, & Alden, 2012)

Treatment Options - Lifestyle Changes

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Ovulation medications help women, especially those that do not have a regular menstrual cycle, by stimulating ovulation and multiple egg release. This increases the opportunities for fertilization

Clomiphene citrate

Letrozole (aromatase inhibitor)

Gonadotropins; follicle-stimulating hormone (FSH), luteinizing hormone (LH), human menopausal gonadotropin (hMG), human chorionic gonadotropin (hCG), & gonadotropin-releasing hormone (GnRH)

Metformin (insulin sensitizing drug) (American Society for Reproductive Medicine, 2014)

Treatment Options - Medical

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Laparoscopic surgery can be performed to remove scar tissue or cysts from ovaries, which may be the cause of infertility.

(WebMD, 2014c)

Treatment Options - Laparoscopy

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During ovulation, sperm is inserted directly into the woman’s uterus

(WebMD, 2014b)

Treatment Options - Intrauterine Insemination

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Collected sperm and mature eggs are placed in a dish together for fertilization to occur. Then about one to three fertilized eggs get inserted into the uterus

(WebMD, 2014a)

Treatment Options - In Vitro Fertilization

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Cultural lag / religious perspectiveInvention and implementation of new technology

occur before cultural acceptance of that technology (e.g. church rejection of ART)

Spiritual characterConception degraded from an intimate act to purely

mechanical

Multiple pregnanciesImplantation of multiple embryos increase the

potential for perinatal mortality(Shreffler, Johnson, & Scheuble, 2010)

Ethical Dilemmas of ART

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Embryo selection process and genetic screening Fertilization outside the maternal body allows the selection and modification of desired

traits

Access of treatmentsLack of standardized regulation of cost, quality, and extent of treatment creates unequal

opportunities

Insurance coverage varies widely from state to state - Michigan state has no infertility insurance mandate

(Chatzinikolaou, 2010)

Ethical Dilemmas of ART

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About 5% of couples living in the 1st world countries experience primary infertility (inability to have any children) or secondary infertility (inability to conceive or carry a pregnancy to term following the birth of one or more children

Research confirmed that the majority of infertility cases can be attributed to a physiological cause in the man or woman

About one-third of the time a physiological problem is identified in the woman, one-third of the time in the man, and about one-tenth of the time in both partners

In approximately 10 to 20% of cases, the basis of infertility cannot be determined

(John Hopkins Medicine, 2016)

Infertility

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Counseling: focused on increasing coping strategies. Research suggests that addressing psychological factors such as depression, anxiety, and stress prior to fertility treatment may lead to a more successful outcome when undergoing fertility assistance to conceive

Group counseling has been demonstrated to be more beneficial to couples than individual counseling because the couples can discuss their issues as a group

Psychotherapy: interpersonal therapy and cognitive behavioral therapy combined has shown to be helpful in providing relief to infertility patients suffering with mild to moderate depression

Interpersonal Therapy: The goal of such therapy is tailored towards education on how to strengthen relationships and/or techniques to resolve conflicts with others

Cognitive Therapy: This form of therapy identifies and tries to change unhealthy patterns of thought or behavior.

(Cousineau & Domar, 2007; Yuit Wah Wong & Ser Hua Tan, 2012)

Therapies to Address the Negative Impacts of Infertility

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Relaxation Techniques: Experts recommend various relaxation techniques to address the significant amount of stress infertility has on males and females

Examples of this therapy include - mindful meditation, deep breathing, guided imagery, and yoga to promote stress management

(Cousineau & Domar, 2007)

Therapies to Address the Negative Impacts of Infertility

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Psychological interventions emphasizing stress management and coping-skills training are proving to have beneficial effects for fertility patients. Still further research is needed to truly understand the correlation between distress and fertility outcome, as well as effective psychosocial interventions

(Klock, 2011)

Psychological Intervention

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A recent qualitative study, the first of its kind, explored the needs of infertile couples

A close overview of the research findings provided the following insight:A need for support and assistance is among infertile couples’ main demands, so that they

can cope with the stress caused by infertility

This need encompasses four categories:Infertility and social support

Infertility and financial support

Infertility and spiritual support

Infertility and information support (Jafarzadeh-Kenarsari, Ghahari, Habibi, & Zargham-Boroujeni, 2015)

Couples Support Requirement

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Studies show in addition to treatment and medical needs, infertile couples are also faced with challenges in emotional, psychological, communicative, cognitive, spiritual and economic aspects that can affect various areas of their lives and lead to new found concerns/problems and demands

Address infertile couples needs and expectations in conjunction with their fertility treatments through patient-centered approaches and couple-based interventions can improve their quality of life and treatment results, and can also relieve negative psychosocial consequences associated with failed fertility

(Jafarzadeh-Kenarsari et al., 2015)

Couples Support Requirement

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Research has found that many women have insufficient education on fertility

Some lack the appropriate information in regards to their menstrual cycle dates

Nurses need to educate women about fertility as soon as the women identify they have difficulties with conceiving

(Hampton, Mazza, & Newton, 2013)

Nursing Role

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Expressive Writing Intervention (EWI) Nurses can educate couples on EWI

This helps couples to indicate their emotions in writing

Research has found that couples that have used EWI have less anxiety in regards in regards to infertility

(Yuit Wah Wong, & Ser Hua Tan, 2012)

Nursing Interventions

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Infertility can be life altering and is a major cause of stress that affects cultures worldwide

The most common emotional symptoms accompanying infertility are anxiety and depression, however couples also frequently experience:

Generalized sadness

Stress

Feeling like a disgrace

Dealing with peers questioning about when they will have children

Loss of privacy

Loss of relationships

Emotionally, couples may experience infertility similar to the way they experience a loss, causing a similar overwhelming grief pattern

(Mosallanejad & Koolee, 2013; Onat & Beji, 2012; Tuzer et al., 2010)

The Emotional Effects

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Infertility often has negative effects on a couple’s marriage, sexual relationship, and self-esteem

Studies suggest that these effects are less severe when both partners equally want children and when they experience similar levels of stress when dealing with infertility

A partner may sometimes distance or detach themselves from the problem as a way of coping, leading to marital problems

Couples who feel that they are not filling their roles by reproducing are likely to experience depression

Emotional consequences of infertility increases with time or as the number of failed treatments increases, shown by an overall decline in marital content in the third year following treatments

(Tuzer et al., 2010)

The Emotional Effects

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Most studies reveal that women are typically more emotionally affected by infertility than men are

This is exhibited by increased display of health concerns, depression, and anxiety

A significant cause of anxiety that women experience is due to invasive procedures or negative bodily effects of interventions that men do not experience when seeking alternatives

Women may experience less severe depression when their partner is the cause of infertility, while the opposite tends to be true when the woman is infertile

(Tuzer et al., 2010)

The Emotional Effects

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There is a significant financial burden associated with trying to have children despite infertility

The United States is the most expensive country for treating infertility, potentially costing approximately 50% of a couple’s net income

The financial burden of treatments directly contributes to the couple’s stress

If treatments are not covered by insurance, they may be too costly, rendering treatment inaccessible

(Connolly, Hoorens, & Chambers, 2010; Tuzer et al., 2010)

The Financial Effects

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Direct Costs - costs needed to cover the price of treatmentConsults

Medications

Lab work

Radiology

Procedures etc.

Indirect Costs - costs to cover anything resulting from treatment

(Connolly et al., 2010)

The Financial Effects

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Treatments commonly cause a woman to become pregnant with multiples

Pregnancies resulting from medical interventions have an increased risk for poor health outcomes than those conceived without intervention

Both circumstances can result in unexpected increased costs associated with infertility

(Connolly et al., 2010)

The Financial Effects

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The stress of infertility can be physically manifested by:An inability to sleep

A significant change in appetite or diet

Smoking

Staying away from places where children may be

No longer having sex for pleasure

Negative career effects

(Onat & Bei, 2012)

The Physical Effects

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Couples may feel absolute exhaustion when dealing with infertility from the addition pressure caused by family and friends expecting the couple to have children

Without proper healthy coping methods, the psychological impact of the stress and depression that accompanies infertility may contribute to the inability of the couple to become pregnant

Stress and depression can make an individual more susceptible to illness

(Gulec, Hassan, Gunes, & Yenilmez,, 2011; Mosallanejad & Koolee, 2013)

The Physical Effects

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Infertility may cause feelings of meaningless

Studies have revealed that many people consider their spirituality to be a major part of their lives

Their spirituality may help them cope, or it may be a cause of additional stress and anxiety

The concept of handing their burden over to a higher power helps provide comfort to some couples dealing with infertility

(Mosallanejad & Koolee, 2013; Roudsari, Allan,& Smith, 2014)

Infertility & Spirituality

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What additional research is needed?

According to reports by the American Pregnancy Association, research in the area of male infertility is lacking. Often when the male is determined to solely be the cause of a couple’s inability to conceive, the case receives the blanket diagnosis of “unknown cause”.

Further research is needed to truly understand the correlation between distress and fertility outcome, as well as effective psychosocial interventions

30 (American Pregnancy Association, 2015; Klock, 2011)