2. Sub fertility
Prepared by: Neha Bhandari
BNS 2nd year

3. General Objective
• At the end of this session participants will be able to
explain about sub fertility.

4. Specific objectives
At the end of this session participants will be able to:
 review the Male and female reproductive organs
 define subfertility
 state the types of sub fertility
 Identify the causes of sub fertility in male and female
 describe the diagnostic tests for sub fertility.
 explain the management of sub fertility.
 state the nursing management of subfertility

5. FEMALE
REPRODUCTIVE
SYSTEM

6. 1.The external female reproductive
organs
 Mons pubis
 Labia majora
 Labia minora
 Clitoris
 Vestibule
 External urethral opening
 Vaginal orifice
 Hymen
 Bartholin’s gland
 Perinium

8. 2.The internal female
reproductive organs
 The vagina
 The uterus
 The uterine tubes
 The ovaries

10. 3.The Accessory organ( The breast
or Mammary gland):

12. 1. Testes =2 6. Ejaculatory duct=2
2. Epididymis=2 7. Prostate gland=1
3. Vas deferens=2 8.Penis=1
4. Spermatic cord=2
5. Seminal vesicles=2

14. Definition
subfertility is defined as failure to conceive
within one or more years of regular
unprotected coitus.
It is a form of reduced fertility or a decreased
chance of getting pregnant, but not a
complete inability to get pregnant

15. Types
a. Primary subfertility: denotes those patient who
have never conceived.
b. Secondary subfertility indicates previous
pregnancy but failure to conceive subsequently

16. Causes of subfertility
I. Male Factors:
A. Defective spermatogenesis:
1.congenital:
• Undescended testis: low sperm production
2.Thermal factor: the scrotal temperature must be 1
and 2 degrees less than body temperature.it is raised in
condition such as:
• Varicocele
• Hydrocele
• Working in hot weather

19. Contd..
3.Infection:
• Mumps orchitis
• Infection of prostate or seminal vesicle
• Chronic systemic illness like bronchiectasis
4.Gonadotrophin suppression:
• Malnutrition
• Heavy smoking
• High alcohol consumption
• Chronic debilitating disease

20. Contd..
5. Endocrine factors:
• Testicular failure
6.loss of sperm motility:
• Asthenozoospermia

21. Contd..
7.Genetic:
• Kallman syndrome: it is the condition in which
hypothalamus is not releasing gonadotrophin
releasing hormone.
• Klienfelter’s syndrome: common chromosomal
abnormality which is associated with hypogonadism
and infertility.

22. Contd..
8.Iatrogenic:
• Radiation
• Cytotoxic drugs, anticonvulsant, antihypertensive
hinder spermatogenesis.
9.Immunological factor:
• Antibodies against spermatozoa surface antigen
may cause infertility which cause clumping of
spermatozoa after ejaculation.

23. Contd..
B. Obstruction of efferent ducts:
• Gonococcal or tubercular infection
• Surgical trauma during vasectomy or hernioraphy.
C. Failure to deposit sperm high in the vagina (coital
problems)
• Erectile dysfunction
• Ejaculatory defects such as premature, retrograde or
absence of ejaculation.
• Hypospadias

25. Contd..
D. Errors in seminal fluid
• Usually low volume of ejaculate
• Low fructose content
• High prostaglandin content
• Increased viscosity

26. II. Female factors
A. ovarian factors:
Hypothalamic:
• Inadequate gonadotrophin releasing hormone
Pituitary:
• Hypo gonadal hypogonadism: A lack of LH and
FSH production caused by problems in pituitary like
Kallman syndrome.

27. Cont..
Ovarian:
• Polycystic ovarian syndrome:
• Ovarian failure
Other endocrine disorders
• Thyroid dysfunction especially hypothyroidism
• Congenital adrenal hyperplasia

28. B. Tubal and peritoneal defect:
These include:
 Peritubal adhesion
 Tubal or peritoneal endometriosis
 Salphingitis
 Polyps within the lumen.

29. C. Uterine factors:
• Endometrial hyperplasia
• Endometritis
• Congenital malformation
• Fibroid uterus
• Inadequate secretory endometrium.
• Acute retroversion of uterus
• Uterine prolapse

30. D. cervical factors
Ineffective sperm penetration due to factors like:
• Chronic cervicitis
• Presence of antisperm antibodies
• Congenital elongation of cervix
• Occlusion of cervical canal with polyp.
• Pinhole OS.
• Abnormal mucus. (excessive, viscous, purulent)

31. E. vaginal factor:
• Atresia of vagina
• Septate vagina
• Transverse vaginal septum

32. III. Combined factor
• advanced age of wife beyond 35 and increased age
of men
• infrequent intercourse, lack of knowledge of coital
technique and timing of coitus to utilize fertile
period
• dyspareunia
• anxiety and apprehension
• use of lubricants during intercourse which may be
spermicidal.

33. Diagnosis:
1. General history:
• Surgical history:
• Medical history
• Menstrual history:
• Gyanecological and obstetric history:
• Contraceptive use
• Sexual history

34. 2. Physical examination
• Reproductive system in male
• Gyanecological examination in female
• speculum examination

35. 3. Diagnostic evaluation
In male:
• Semen fluid analysis
• Serum FSH, LH, testosterone, Prolactin and TSH
• Testicular biopsy
• Trans rectal ultrasound(TRUS), for seminal vesicle,
prostate and ejaculatory duct obstruction
• Karyotype analysis is done to detect klinfelter’s
syndrome.
• Immunological test: to detect sperm antibodies.
• Culture and sensitivity test to detect microorganisms
in prostatic fluid.

36. Cont..
In female
1. Diagnosis of ovulation:
• Basal body temperature(BBT):
• Cervical mucus study
• Hormone estimation
• Transvaginal ultrasound
• Endometrial biopsy

37. 2. Assessment of tubal patency:
• Insufflation test
• Hysterosalphingography
• USG
• Laparoscopy
3. Evaluation of cervical factors:
• Post coital test
• Sperm cervical mucus contact test
4. Blood tests for syphilis, rubella and HIV.
5. Swabs for chlamydia and gonorrhea.

38. Management
IN male:
For general health improvement, reduction of
weight in obese, avoidance of alcohol and heavy
smoking.
Medications that interfere with spermatogenesis
should be avoided like cytotoxic drug. Beta blocker,
nitrofurantoin, antihypertensive, anticonvulsant etc.
In hypogonadotropic-hypogonadism
• Testosterone replacement therapy.
.

39. Contd..
In hyper gonadotrophic hypogonadism
• Clomiphene citrate 25 mg orally daily for 3 months .
 In presence of antisperm antibodies, dexamethasone
at bed time may be prescribed.
Genital tract infection requires prolonged course of
antibiotics. Generally, doxycycline or erythromycin
is given for 4-6weeks.

40. Contd..
• In genetic abnormality, artificial insemination with
donor sperm is the option.
• Surgical correction for varicocele and hydrocele.
• Orchidopexy in undescended testis.

41. In Female
Anovulation (with amenorrhea) can be treated with
induction of ovulation with:
• Clomiphene citrate to increase level of FSH, LH.
• Recombinant FSH
• Recombinant hCG
• GnRH analogs

42. Mgmt contd..
Correction of biochemical abnormality:
• Metformin for hyperinsulinemia.
• Dexamethasone for androgen excess
• Bromocriptine for prolactin excess.
Substitution therapy:
• Thyroxin for hypothyroidism
• Antidiabetic drugs for diabetes mellitus

43. Mgmt cont..
• Tubal damage may be corrected with surgery
tuboplasty.
• The operations in uterus like myomectomy (in
submucosa fibroid), Metroplasty (removal of
septum).
• Surgery for congenital elongated cervix.
• Antibiotics for reproductive tract infections.

44. Assisted Reproductive Technologies(ART)
• Intrauterine insemination
• Invitro fertilization(IVF) and embryo transfer(IVF-
ET)
• Gamete Intrafallopian Transfer(GIFT)
• Zygote Intrafallopian Transfer(ZIFT)
• Intra-Cytoplasmic sperm injection(ICSI)
• Surrogacy

45. Nursing management
1. Assessment:
• General history, past and present medical history,
gynecological and obstetric history (if any),
duration of infertility and sexual history should be
taken.
• Physical examination
• Reports of investigations and diagnostic test
• Psychological and emotional state of patient which
is common like low self-esteem, anxiety,
depression.

46. 2. Nursing diagnosis
• Situational low self-esteem related to seeming
inability to conceive.
• Deficient knowledge related to new procedures and
treatment as evidenced by patient expressing
confusion.

47. 3. Nursing intervention
• Provide emotional support by providing
opportunities to explore the feelings and queries and
answering properly and clearly in simple language.
• Reassure and provide information about availability
of different treatment modalities and diagnostic
tests.

48. Contd..
• Assist the patient during therapeutic interventions
like diagnostic tests and treatment procedures.
• Provide preoperative and post-operative care for
patient undergoing surgery.
• Counsel the couple about availability of different
assisted reproductive technologies.

50. Home assignment:
Read about neuroendocrinology in relation to
reproduction.

51. Plan for next class
Dysfunctional uterine bleeding(DUB).

52. References
• Jacob Annamma,A comprehensive text book of
midwifery and gyanecological Nursing, 4th
edition(2015), page no 857-866, Jaypee Brothers
Medical Publishers(P) LTD, New delhi.
• Novak R Edmund, Jones S. Georgeanna, Jones W.
Howard, Novak’s Textbook of Gynecology, Ninth
Edition(1975), page no 625-648, S. Chand and
Co(P) LTD, New delhi .
• Health Learning Materials Centre, TU IOM,
Kathmandu , A Textbook of Adult Health Nursing,
Re print (2010), page no 254- 256,Sopan Press P.
Ltd, Dillibazar Kathmandu.

53. • Ashalatha PR, Deepa G, Anatomy And Physiology
For Nurses, 4th edition(2015), page no469-
497,Jyapee brothers medical publishers, New
Delhi.
• Shrestha Tumla, A textbook of educational science
for nurses, 1st edition(2074), Heritage publishers
and distributers.
• Konar Hiralal, Dc Dutta’s textbook of gyanecology,
7th edition(2016), page no. 217-240, Jaypee brothers
medical publishers(P) Ltd.
• Presannakumari B, Postgraduate gyanecology, 1st
edition(2011), page no. 116-120, , Jaypee Brothers
Medical Publishers(P) LTD, New delhi.